FDA Adverse Event
Injury
Summary report: N
CAPSURE Z
MDR report key: 3994030
·
Received August 8, 2014
Report
- Report Number
- 2649622-2014-09008
- Event Type
- Injury
- Date Received
- August 8, 2014
- Date of Event
- June 19, 2014
- Report Date
- June 19, 2014
- Manufacturer
- MPRI
- Product Code
- DTB
- PMA / PMN Number
- P850089
- 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: 5068-58 LEAD, (B)(6) 1999. (B)(4).
Description of Event or Problem · 1
IT WAS REPORTED THE RIGHT ATRIAL (RA) LEAD EXHIBITED HIGH AND VARIABLE THRESHOLDS. THE RA LEAD WAS CAPPED AND REPLACED. NO PATIENT COMPLICATIONS HAVE BEEN REPORTED AS A RESULT OF THIS EVENT.
Devices
| Seq | Brand | Generic | Product Code | Manufacturer | Model | Lot | UDI-DI |
|---|---|---|---|---|---|---|---|
| 471186 | CAPSURE Z | ELECTRODE, PACEMAKER, PERMANENT | DTB | MPRI | 5534-45 |
Patients
| Seq | Age | Sex | Outcome | Treatment |
|---|---|---|---|---|
| 1 | 00084 YR | Hospitalization| R | P1501DR IPG (B)(6) 2010 |