BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    CPS AIM SL

    MDR report key: 2905379 · Received January 9, 2013

    Report

    Report Number
    2017865-2013-00814
    Event Type
    Malfunction
    Date Received
    January 9, 2013
    Date of Event
    November 20, 2012
    Manufacturer
    ST JUDE MEDICAL CARDIAC RHYTHM MANAGEMENT DIVISION
    Product Code
    DQY
    PMA / PMN Number
    NA
    Removal / Correction Number
    NA
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    WA
    Reporter Occupation
    OTHER HEALTH CARE PROFESSIONAL

    Narratives

    Additional Manufacturer Narrative · 1

    ALL INFORMATION PROVIDED BY MANUFACTURER, NO MEDWATCH FORM WAS RECEIVED.

    Description of Event or Problem · 1

    IT WAS REPORTED THAT DURING THE ATTEMPT TO WITHDRAW THE INNER SHEATH THE TIP BROKE OFF IN THE CORONARY SINUS.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    11782 CPS AIM SL INNER CATHETER DQY ST JUDE MEDICAL CARDIAC RHYTHM MANAGEMENT DIVISION DS2N023-65 NA

    Patients

    Seq Age Sex Outcome Treatment
    1 68 YR