BEUDAMED
    FDA Adverse Event Injury Summary report: N

    CAPSUREFIX NOVUS

    MDR report key: 2790152 · Received October 15, 2012

    Report

    Report Number
    2649622-2012-14996
    Event Type
    Injury
    Date Received
    October 15, 2012
    Manufacturer
    MEDTRONIC PUERTO RICO, INC.
    Product Code
    DTB
    PMA / PMN Number
    P930039/S009
    Adverse Event
    Yes
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    PA, 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. EVALUATION SUMMARY: (B)(4) - THE PARTIAL LEAD WAS RETURNED IN SEGMENTS AND WAS ANALYZED. NO ANOMALIES WERE FOUND. ALL CONDUCTORS WERE DISTORTED AND BLOOD/BODY FLUID WAS PRESENT (NOT OBSTRUCTED). THE OUTER INSULATION WAS BREACHED CUT, AND EXHIBITED A COSMETIC DEPRESSION AND A WHITE SUBSTANCE. BLOOD WAS FOUND IN/ON THE HELIX/LOBE MECHANISM AND TISSUE WAS FOUND ON THE HELIX. THE LEAD APPEARED TO HAVE BEEN STRETCHED AND EXHIBITED APPARENT EXPLANT DAMAGE.

    Description of Event or Problem · 1

    IT WAS REPORTED THAT THE RIGHT VENTRICULAR (RV) LEAD EXHIBITED HIGH THRESHOLDS. THE LEAD WAS EXPLANTED AND REPLACED. NO PATIENT COMPLICATIONS HAVE BEEN REPORTED AS A RESULT OF THIS EVENT.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 CAPSUREFIX NOVUS IMPLANTABLE PACING LEAD DTB MEDTRONIC PUERTO RICO, INC. 5076

    Patients

    Seq Age Sex Outcome Treatment
    1 23 YR Hospitalization| R 5076 IMPLANTABLE PACING LEAD| E2DR01 IMPLANTABLE PULSE GENERATOR