BEUDAMED
    FDA Adverse Event Injury Summary report: N

    ELLIPSE VR, DF4 CONNECTOR

    MDR report key: 3220022 · Received July 11, 2013

    Report

    Report Number
    2938836-2013-04437
    Event Type
    Injury
    Date Received
    July 11, 2013
    Date of Event
    March 29, 2013
    Manufacturer
    ST JUDE MEDICAL CARDIAC RHYTHM MANAGEMENT DIVISION
    Product Code
    LWS
    PMA / PMN Number
    P910023
    Removal / Correction Number
    NA
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    IL
    Reporter Occupation
    OTHER HEALTH CARE PROFESSIONAL

    Narratives

    Additional Manufacturer Narrative · 1

    ALL INFORMATION PROVIDED BY MANUFACTURER, NO MEDWATCH FORM WAS RECEIVED ANALYSIS WAS NORMAL. NO ANOMALY WAS FOUND.

    Description of Event or Problem · 1

    IT WAS REPORTED THAT THE SYSTEM WAS EXPLANTED DUE TO INFECTION.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    319811 ELLIPSE VR, DF4 CONNECTOR IMPLANTABLE CARDIOVERTER DEFIBRILLATOR LWS ST JUDE MEDICAL CARDIAC RHYTHM MANAGEMENT DIVISION CD1311-36Q NA

    Patients

    Seq Age Sex Outcome Treatment
    1 72 YR Required Intervention 7120Q/58, BNP022033