BEUDAMED
    FDA Adverse Event Injury Summary report: N

    ATTAIN OTW

    MDR report key: 2952086 · Received February 9, 2013

    Report

    Report Number
    2649622-2013-00379
    Event Type
    Injury
    Date Received
    February 9, 2013
    Date of Event
    September 2, 2004
    Report Date
    November 7, 2012
    Manufacturer
    MPRI
    Product Code
    DTB
    PMA / PMN Number
    P010015
    Adverse Event
    Yes
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    IT
    Reporter Occupation
    PHYSICIAN

    Narratives

    Additional Manufacturer Narrative · 1

    THIS EVENT OCCURRED OUTSIDE THE US WHERE THE SAME MODEL IS DISTRIBUTED. ALL INFORMATION PROVIDED IS INCLUDED IN THIS REPORT. PATIENT INFORMATION IS NOT GENERALLY AVAILABLE DUE TO CONFIDENTIALITY CONCERNS. (B)(4).

    Description of Event or Problem · 1

    IT WAS REPORTED THAT THE PATIENT WAS HOSPITALIZED DUE TO LEFT VENTRICULAR (LV) LEAD DISLODGEMENT. THE LEAD WAS EXPLANTED AND REPLACED. THE PATIENT WAS ENROLLED IN THE CLINICALSERVICE PROJECT. NO PATIENT COMPLICATIONS HAVE BEEN REPORTED AS A RESULT OF THIS EVENT.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    57060 ATTAIN OTW ELECTRODE, PACEMAKER, PERMANENT DTB MPRI 4194

    Patients

    Seq Age Sex Outcome Treatment
    1 00066 YR Hospitalization| R