BEUDAMED
    FDA Adverse Event Death Summary report: N

    CAPSUREFIX NOVUS

    MDR report key: 3242516 · Received July 23, 2013

    Report

    Report Number
    2649622-2013-08238
    Event Type
    Death
    Date Received
    July 23, 2013
    Date of Event
    April 29, 2013
    Report Date
    June 28, 2013
    Manufacturer
    MEDTRONIC PUERTO RICO
    Product Code
    DTB
    PMA / PMN Number
    P930039
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    US
    Reporter Occupation
    PATIENT

    Narratives

    Additional Manufacturer Narrative · 1

    THE INFORMATION SUBMITTED REFLECTS ALL RELEVANT DATA RECEIVED. IF ADDITIONAL RELEVANT INFORMATION IS RECEIVED, A SUPPLEMENTAL REPORT WILL BE SUBMITTED. ATTEMPT(S) FOR ADDITIONAL INFORMATION REGARDING THE DEATH WITH THE FUNERAL HOME AND THE PHYSICIAN OFFICE WERE UNSUCCESSFUL. HOWEVER, IF REQUESTED ADDITIONAL INFORMATION IS SUBSEQUENTLY RECEIVED IT WOULD BE PROCESSED AND CONSIDERED ACCORDINGLY. PRODUCT ID: D334DRG, IMPLANTED: (B)(6) 2013; PRODUCT ID: 694965, IMPLANTED: (B)(6) 2006. (B)(4).

    Description of Event or Problem · 1

    IT WAS REPORTED THAT THE PATIENT EXPERIENCED LOSS OF CONSCIOUSNESS ON THREE OCCASIONS. THERE WERE EPISODES OF SHOCKS AND THE PATIENT WAS ADMITTED TWO TIMES TO THE HOSPITAL. THE SPOUSE QUESTIONED IF THE DEVICE OR LEADS WERE MALFUNCTIONING OR IF THE ARRHYTHMIAS WERE CAUSED BY THE DEVICE. THE PATIENT CONTINUES TO FEEL CHEST PAIN. FOLLOW-UP ATTEMPT TO ACQUIRE ADDITIONAL INFORMATION FROM THE CLINIC REPORTED THE PATIENT AS DECEASED WITH NO CAUSE OF DEATH AVAILABLE.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    343224 CAPSUREFIX NOVUS ELECTRODE, PACEMAKER, PERMANENT DTB MEDTRONIC PUERTO RICO 5076-52

    Patients

    Seq Age Sex Outcome Treatment
    1 00074 YR Death