BEUDAMED
    FDA Adverse Event Injury Summary report: N

    IDENTITY ADX SR

    MDR report key: 4152197 · Received January 13, 2014

    Report

    Report Number
    2017865-2014-06589
    Event Type
    Injury
    Date Received
    January 13, 2014
    Date of Event
    December 19, 2011
    Manufacturer
    ST. JUDE MEDICAL, CARDIAC RHYTHM MANAGEMENT DIVISI
    Product Code
    DXY
    Adverse Event
    Yes
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Occupation
    NURSE

    Narratives

    Additional Manufacturer Narrative · 1

    ALL INFO 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.

    Description of Event or Problem · 1

    IT WAS REPORTED THAT THE PT PRESENTED IN CLINIC FOR FOLLOW UP. THE PULSE GENERATOR WAS UNABLE TO INTERROGATE AND EXHIBITED LOSS OF CAPTURE. THE DEVICE WAS EXPLANTED AND REPLACED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    23500 IDENTITY ADX SR IMPLANTABLE PACEMAKER PULSE GENERATOR DXY ST. JUDE MEDICAL, CARDIAC RHYTHM MANAGEMENT DIVISI 5180

    Patients

    Seq Age Sex Outcome Treatment
    1 88 YR Required Intervention