BEUDAMED
    FDA Adverse Event Injury Summary report: N

    CAPSURE SP NOVUS

    MDR report key: 2201382 · Received August 11, 2011

    Report

    Report Number
    2649622-2011-11102
    Event Type
    Injury
    Date Received
    August 11, 2011
    Date of Event
    May 10, 2011
    Manufacturer
    MEDTRONIC PUERTO RICO, INC.
    Product Code
    DTB
    PMA / PMN Number
    P830061/S27
    Removal / Correction Number
    ASKU
    Adverse Event
    Yes
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    WA, US
    Reporter Occupation
    PHYSICIAN

    Narratives

    Additional Manufacturer Narrative · 1

    THE INFORMATION SUBMITTED REFLECTS ALL RELEVANT DATA RECEIVED. IF ADDITIONAL RELEVANT INFORMATION IS RECEIVED, A SUPPLEMENTAL REPORT WILL BE SUBMITTED.

    Description of Event or Problem · 1

    IT WAS REPORTED THAT THE DURING THE DEVICE CHANGE OUT, THE PHYSICIAN NOTICED THAT THERE WAS SOME DISCOLORATION ON THE RIGHT VENTRICULAR AND RIGHT ATRIAL LEADS. THE ATRIAL LEAD ALSO APPEARED TO HAVE EXPOSED CONDUCTOR WIRE. THE PHYSICIAN CHOSE TO REPAIR THE ATRIAL LEAD WITH A SPLICE KIT. BOTH LEADS ARE STILL IN USE. NO PATIENT COMPLICATIONS HAVE BEEN REPORTED AS A RESULT OF THIS EVENT.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 CAPSURE SP NOVUS IMPLANTABLE PACING LEAD DTB MEDTRONIC PUERTO RICO, INC. 4092 ASKU

    Patients

    Seq Age Sex Outcome Treatment
    1 77 YR Required Intervention 7088B IMPLANTABLE PULSE GENERATOR