BEUDAMED
    FDA Adverse Event Injury Summary report: N

    CAPSURE SP

    MDR report key: 3991266 · Received August 8, 2014

    Report

    Report Number
    2649622-2014-08218
    Event Type
    Injury
    Date Received
    August 8, 2014
    Date of Event
    May 5, 2014
    Report Date
    May 23, 2014
    Manufacturer
    MPRI
    Product Code
    DTB
    PMA / PMN Number
    P830061
    Adverse Event
    Yes
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    TN, 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: 4524-53 LEAD IMPLANTED: (B)(6) 2001. (B)(4).

    Description of Event or Problem · 1

    IT WAS REPORTED THAT THE RIGHT VENTRICULAR LEAD HAD LOW PACING IMPEDANCE AND A POLARITY SWITCH TO UNIPOLAR PACING OCCURRED. THE PATIENT EXPERIENCED POCKET STIMULATION IN THE UNIPOLAR PACING CONFIGURATION SO THE LEAD WAS CAPPED. A NEW LEAD WAS ATTEMPTED; HOWEVER IT HAD HIGH IMPEDANCE IN SEVERAL LOCATIONS. THE PHYSICIAN SUSPECTED THE LEAD WAS DEFECTIVE. THE ATTEMPTED LEAD WAS NOT USED AND ANOTHER 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
    467957 CAPSURE SP ELECTRODE, PACEMAKER, PERMANENT DTB MPRI 4024

    Patients

    Seq Age Sex Outcome Treatment
    1 00067 YR Hospitalization| R ADDR01 IPG