FDA Adverse Event Injury Summary report: N

REPLY

MDR report key: 3829782 · Received May 23, 2014

Report

Report Number
1000165971-2014-00296
Event Type
Injury
Date Received
May 23, 2014
Date of Event
April 18, 2014
Report Date
April 23, 2014
Manufacturer
SORIN GROUP ITALIA S.R.L. - CRM FACILITY
Product Code
NVZ
PMA / PMN Number
PP950029
Adverse Event
Yes
Report Source
Manufacturer report
Reporter Location
JA
Reporter Occupation
PHYSICIAN

Narratives

Additional Manufacturer Narrative · 1

ANALYSIS RESULTS SUGGEST A LEAD OR A CONNECTION ISSUE AT ATRIAL LEVEL. RECOMMENDATIONS HAVE BEEN PROVIDED ON 1 AUGUST 2014. NEW FILES RECEIVED FOR THE FOLLOW-UP PERFORMED ON 25 JULY 2014.

Description of Event or Problem · 1

DURING A REGULAR PACEMAKER CHECK ON (B)(6) 2014, A MESSAGE SHOWING THAT THE DEVICE IS IN STANDBY MODE WAS DISPLAYED. NO OTHER MESSAGES WERE DISPLAYED AT THAT TIME. DURING ATRIAL SENSITIVITY TEST, IT WAS UNABLE TO MEASURE ATRIAL SENSING AMPLITUDE (AP-VP MARKERS WERE DISPLAYED), EVEN AFTER RE-PROGRAMMING THE ATRIAL SENSITIVITY TO MORE SENSITIVE VALUES. DURING ATRIAL PACING THRESHOLD TEST, CAPTURE FAILURE WAS OBSERVED. ATRIAL THRESHOLD WAS ALSO IMMEASURABLE. SINCE ATRIAL LEAD IMPEDANCE WAS MEASURED ABOVE 3000OHMS, LEAD FRACTURE WAS SUSPECTED. ATRIAL LEAD POLARITY WAS THEN CHANGED FROM BIPOLAR TO UNIPOLAR SETTINGS BUT CAPTURE FAILURE WAS ALSO OBSERVED DURING PACING THRESHOLD TEST. LEAD FRACTURE POINT WAS NOT IDENTIFIED ON X-RAY PHOTO. PACING MODE WAS RE-PROGRAMMED FROM DDDR (WITH MV+G SENSOR) TO VVIR (WITH MV+G SENSOR) AT THE END OF THIS FOLLOW-UP. THE NEXT FOLLOW-UP WILL BE PERFORMED IN THREE MONTHS. AN ANALYSIS IS REQUESTED. PRELIMINARY ANALYSIS SHOWED A LEAD OR CONNECTION ISSUE AT ATRIAL SIDE.

Description of Event or Problem · 1

DURING A REGULAR PACEMAKER CHECK ON (B)(6) 2014, A MESSAGE SHOWING THAT THE DEVICE IS IN STANDBY MODE WAS DISPLAYED. NO OTHER MESSAGES WERE DISPLAYED AT THAT TIME. DURING ATRIAL SENSITIVITY TEST, IT WAS UNABLE TO MEASURE ATRIAL SENSING AMPLITUDE (AP-VP MARKERS WERE DISPLAYED), EVEN AFTER RE-PROGRAMMING THE ATRIAL SENSITIVITY TO MORE SENSITIVE VALUES. DURING ATRIAL PACING THRESHOLD TEST, CAPTURE FAILURE WAS OBSERVED. ATRIAL THRESHOLD WAS ALSO IMMEASURABLE. SINCE ATRIAL LEAD IMPEDANCE WAS MEASURED ABOVE 3000OHMS, LEAD FRACTURE WAS SUSPECTED. ATRIAL LEAD POLARITY WAS THEN CHANGED FROM BIPOLAR TO UNIPOLAR SETTINGS BUT CAPTURE FAILURE WAS ALSO OBSERVED DURING PACING THRESHOLD TEST. LEAD FRACTURE POINT WAS NOT IDENTIFIED ON X-RAY PHOTO. PACING MODE WAS RE-PROGRAMMED FROM DDDR (WITH MV+G SENSOR) TO VVIR (WITH MV+G SENSOR) AT THE END OF THIS FOLLOW-UP. THE NEXT FOLLOW-UP WILL BE PERFORMED IN THREE MONTHS. AN ANALYSIS IS REQUESTED. PRELIMINARY ANALYSIS SHOWED A LEAD OR CONNECTION ISSUE AT ATRIAL SIDE.

Description of Event or Problem · 1

DURING A REGULAR PACEMAKER CHECK ON (B)(6) 2014, A MESSAGE SHOWING THAT THE DEVICE IS IN STANDBY MODE WAS DISPLAYED. NO OTHER MESSAGES WERE DISPLAYED AT THAT TIME. DURING ATRIAL SENSITIVITY TEST, IT WAS UNABLE TO MEASURE ATRIAL SENSING AMPLITUDE (AP-VP MARKERS WERE DISPLAYED), EVEN AFTER RE-PROGRAMMING THE ATRIAL SENSITIVITY TO MORE SENSITIVE VALUES. DURING ATRIAL PACING THRESHOLD TEST, CAPTURE FAILURE WAS OBSERVED. ATRIAL THRESHOLD WAS ALSO IMMEASURABLE. SINCE ATRIAL LEAD IMPEDANCE WAS MEASURED ABOVE 3000OHMS, LEAD FRACTURE WAS SUSPECTED. ATRIAL LEAD POLARITY WAS THEN CHANGED FROM BIPOLAR TO UNIPOLAR SETTINGS BUT CAPTURE FAILURE WAS ALSO OBSERVED DURING PACING THRESHOLD TEST. LEAD FRACTURE POINT WAS NOT IDENTIFIED ON X-RAY PHOTO. PACING MODE WAS RE-PROGRAMMED FROM DDDR (WITH MV+G SENSOR) TO VVIR (WITH MV+G SENSOR) AT THE END OF THIS FOLLOW-UP. THE NEXT FOLLOW-UP WILL BE PERFORMED IN THREE MONTHS. AN ANALYSIS IS REQUESTED. PRELIMINARY ANALYSIS SHOWED A LEAD OR CONNECTION ISSUE AT ATRIAL SIDE.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
307811 REPLY PULSE GENERATOR, PERMANENT, IMPLANTABLE NVZ SORIN GROUP ITALIA S.R.L. - CRM FACILITY REPLY DR 2587

Patients

Seq Age Sex Outcome Treatment
1 Required Intervention