BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    IDENTITY XL DR

    MDR report key: 4151038 · Received January 13, 2014

    Report

    Report Number
    2017865-2014-06599
    Event Type
    Malfunction
    Date Received
    January 13, 2014
    Date of Event
    May 13, 2011
    Manufacturer
    ST. JUDE MEDICAL, CRMD
    Product Code
    LWP
    PMA / PMN Number
    NA
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    PA, US
    Reporter Occupation
    PHYSICIAN

    Narratives

    Additional Manufacturer Narrative · 1

    ALL INFO WAS PROVIDED BY MFR, 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. EVAL DESCRIPTION: THE REPORTED FIELD EVENT OF SET SCREW ANOMALY WAS CONFIRMED IN THE LABORATORY. VENTRICULAR SET SCREW COULD NOT BE TIGHTENED DOWN DUE TO SEPTUM MATERIAL INSET SCREW INSET.

    Description of Event or Problem · 1

    IT WAS REPORTED THAT THE SET SCREW COULD NOT BE UNSCREWED. THE DEVICE WAS REPLACED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    31679 IDENTITY XL DR IMPLANTABLE PACEMAKER PULSE GENERATOR LWP ST. JUDE MEDICAL, CRMD 5376

    Patients

    Seq Age Sex Outcome Treatment
    1 90 YR