BEUDAMED
    FDA Adverse Event Injury Summary report: N

    CAPSUREFIX NOVUS

    MDR report key: 3860703 · Received June 10, 2014

    Report

    Report Number
    2649622-2014-05327
    Event Type
    Injury
    Date Received
    June 10, 2014
    Date of Event
    April 2, 2014
    Report Date
    April 2, 2014
    Manufacturer
    MPRI
    Product Code
    DTB
    PMA / PMN Number
    P930039
    Adverse Event
    Yes
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    CA, US
    Reporter Occupation
    PHYSICIAN

    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. CONCOMITANT PRODUCT: 4076-52, LEAD, (B)(6) 2006. (B)(4).

    Description of Event or Problem · 1

    IT WAS REPORTED THAT THE RIGHT VENTRICULAR (RV) LEAD HAD DISLODGED. THE RV LEAD WAS CAPPED AND REMAINS OUT OF SERVICE INSIDE THE PATIENT. A NEW RV LEAD WAS IMPLANTED. IT WAS FURTHER REPORTED THAT THE RIGHT ATRIAL (RA) LEAD HAD ALSO DISLODGED. THE RA LEAD WAS FOUND TO HAVE HIGH THRESHOLDS. THE RA LEAD WAS CAPPED AND REMAINS OUT OF SERVICE INSIDE THE PATIENT. A NEW RA LEAD WAS IMPLANTED. NO PATIENT COMPLICATIONS HAVE BEEN REPORTED AS A RESULT OF THIS EVENT.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    340592 CAPSUREFIX NOVUS ELECTRODE, PACEMAKER, PERMANENT DTB MPRI 5076-65

    Patients

    Seq Age Sex Outcome Treatment
    1 00070 YR Hospitalization| R E2DR01AA IPG