BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    IDENTITY ADX XL DR

    MDR report key: 4140367 · Received January 13, 2014

    Report

    Report Number
    2017865-2014-05874
    Event Type
    Malfunction
    Date Received
    January 13, 2014
    Date of Event
    December 13, 2012
    Manufacturer
    ST. JUDE MEDICAL, INC. CRMD
    Product Code
    DXY
    PMA / PMN Number
    NA
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    DE, US
    Reporter Occupation
    PHYSICIAN

    Narratives

    Additional Manufacturer Narrative · 1

    ALL INFORMATION PROVIDED BY MANUFACTURER, NO MEDWATCH FORM WAS RECEIVED. THIS HISTORICAL COMPLAINT IS BEING FILED AS PART OF A RETROSPECTIVE REVIEW OF COMPLAINT FILES IN RESPONSE TO A RECENT FDA INSPECTION. THERE IS NO CHANGE TO THE ACTUAL PERFORMANCE OF THE PRODUCT AND THIS REPORT ONLY REPRESENTS AN ENHANCEMENT TO THE REPORTING CRITERIA GOING FORWARD.

    Description of Event or Problem · 1

    IT WAS REPORTED THAT A PATIENT PRESENTED IN CLINIC FOR A FOLLOW UP. THE DEVICE EXHIBITED BACKUP VVI OPERATION. A DEVICE REPLACEMENT WAS SCHEDULED ELECTIVELY DUE TO THE DEVICE APPROACHING ERI.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    33159 IDENTITY ADX XL DR IMPLANTABLE PACEMAKER PULSE GENERATOR, DXY DXY ST. JUDE MEDICAL, INC. CRMD 5386

    Patients

    Seq Age Sex Outcome Treatment
    1 69 YR