BEUDAMED
    FDA Adverse Event Injury Summary report: N

    DURATA STS OPTIM ACTIVE FIXATION, DF4 CONNECTOR

    MDR report key: 3220234 · Received July 11, 2013

    Report

    Report Number
    2938836-2013-04341
    Event Type
    Injury
    Date Received
    July 11, 2013
    Date of Event
    May 14, 2013
    Manufacturer
    ST JUDE MEDICAL CARDIAC RHYTHM MANAGEMENT DIVISION
    Product Code
    NVY
    PMA / PMN Number
    P950022
    Removal / Correction Number
    NA
    Adverse Event
    Yes
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    NJ
    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 THE PATIENT PARTICIPATED IN NON- SPECIFIED ACTIVITIES AND RECEIVED SHOCKS AS A RESULT. UPON EVALUATION, LEAD DISLODGEMENT WAS OBSERVED. THE LEAD WAS REPOSITIONED SUCCESSFULLY AND PATIENT WILL BE MONITORED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    320555 DURATA STS OPTIM ACTIVE FIXATION, DF4 CONNECTOR DEFIBRILLATION LEAD NVY ST JUDE MEDICAL CARDIAC RHYTHM MANAGEMENT DIVISION 7121Q/65 NA

    Patients

    Seq Age Sex Outcome Treatment
    1 52 YR Required Intervention