BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    IDENTITY ADX SR

    MDR report key: 4142998 · Received January 13, 2014

    Report

    Report Number
    2017865-2014-05598
    Event Type
    Malfunction
    Date Received
    January 13, 2014
    Date of Event
    December 12, 2011
    Manufacturer
    ST. JUDE MEDICAL, CRMD
    Product Code
    DXY
    PMA / PMN Number
    NA
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    US
    Reporter Occupation
    OTHER

    Narratives

    Additional Manufacturer Narrative · 1

    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. INITIAL REPORTER: COMPANY REP.

    Description of Event or Problem · 1

    IT WAS REPORTED THAT THE PULSE GENERATOR WAS UNABLE TO INTERROGATE. THE DEVICE WAS EXPLANTED AND REPLACED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    31662 IDENTITY ADX SR IMPLANTABLE PACEMAKER PULSE GENERATOR DXY ST. JUDE MEDICAL, CRMD 5180

    Patients

    Seq Age Sex Outcome Treatment
    1 76 YR