FDA Adverse Event
Malfunction
Summary report: N
SCREW-IN
MDR report key: 2791668
·
Received October 15, 2012
Report
- Report Number
- 2649622-2012-15149
- Event Type
- Malfunction
- Date Received
- October 15, 2012
- Date of Event
- August 28, 2011
- Manufacturer
- MEDTRONIC PUERTO RICO, INC.
- Product Code
- DTB
- PMA / PMN Number
- K896313
- Product Problem
- Yes
- Report Source
- Manufacturer report
- Reporter Location
- NC, 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 THERE WAS AN ATRIAL LEAD WARNING FOR LOW IMPEDANCE THAT OCCURRED A YEAR PRIOR TO CHECK-UP. IT WAS THOUGHT THAT THE PATIENT HAD GALL BLADDER SURGERY DURING THE TIME OF THE LOW IMPEDANCE. THE LEAD REMAINS 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 | SCREW-IN | IMPLANTABLE PACING LEAD | DTB | MEDTRONIC PUERTO RICO, INC. | 4058M |
Patients
| Seq | Age | Sex | Outcome | Treatment |
|---|---|---|---|---|
| 1 | 51 YR | Other | (B)(4) IMPLANTABLE PULSE GENERATOR| 4058M IMPLANTABLE PACING LEAD |