BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    CAPSUREFIX NOVUS

    MDR report key: 2811767 · Received October 31, 2012

    Report

    Report Number
    2649622-2012-16634
    Event Type
    Malfunction
    Date Received
    October 31, 2012
    Date of Event
    September 27, 2012
    Manufacturer
    MEDTRONIC PUERTO RICO, INC.
    Product Code
    DTB
    PMA / PMN Number
    P930039/S009
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    BE
    Reporter Occupation
    PHYSICIAN

    Narratives

    Additional Manufacturer Narrative · 1

    THIS EVENT OCCURRED OUTSIDE THE US. ALL INFORMATION PROVIDED IS INCLUDED IN THIS REPORT. IF ADDITIONAL RELEVANT INFORMATION IS RECEIVED, A SUPPLEMENTAL REPORT WILL BE SUBMITTED. PATIENT INFORMATION IS NOT GENERALLY AVAILABLE DUE TO CONFIDENTIALITY CONCERNS. EVALUATION SUMMARY (B)(4): THE FULL LEAD WAS RETURNED AND ANALYZED. THE HELIX/LOBE WAS DISTORTED/BENT. THE PROXIMAL CONDUCTOR AND THE LEAD WERE STRETCHED. VISUAL ANALYSIS REVEALED THE LEAD WAS DAMAGED AT IMPLANT. IT CANNOT BE DETERMINED AT THIS TIME WHEN AND HOW THE BEND OCCURRED.

    Description of Event or Problem · 1

    IT WAS REPORTED THAT DURING THE IMPLANT ATTEMPT UPON OPENING THE BOX FOR THE LEAD, THE PHYSICIAN NOTED THAT THE SCREW WAS EXPOSED AND THE SCREW WAS NOT PERFECTLY IN LINE WITH THE LEAD BODY. IT WAS NOT POSSIBLE TO RETRACT THE SCREW. THE LEAD WAS NOT USED AND A NEW LEAD WAS IMPLANTED. 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 Other