FDA Adverse Event
Injury
Summary report: N
FORTIFY ASSURA DR
MDR report key: 4160788
·
Received January 13, 2014
Report
- Report Number
- 2938836-2014-01882
- Event Type
- Injury
- Date Received
- January 13, 2014
- Date of Event
- December 7, 2012
- Manufacturer
- ST. JUDE MEDICAL INC. CRMD
- Product Code
- LWS
- PMA / PMN Number
- P910023
- Adverse Event
- Yes
- Product Problem
- Yes
- Report Source
- Manufacturer report
- Reporter Location
- US
- Reporter Occupation
- PHYSICIAN
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.
Description of Event or Problem · 1
IT WAS REPORTED THAT THE PT RECEIVED INAPPROPRIATE HIGH VOLTAGE THERAPY WHILE IN SINUS. THE DEVICE WAS REPROGRAMMED AND REMAINED IMPLANTED.
Devices
| Seq | Brand | Generic | Product Code | Manufacturer | Model | Lot | UDI-DI |
|---|---|---|---|---|---|---|---|
| 26610 | FORTIFY ASSURA DR | IMPLANTABLE CARDIOVERTER DEFIBRILLATOR | LWS | ST. JUDE MEDICAL INC. CRMD | CD2257-40 |
Patients
| Seq | Age | Sex | Outcome | Treatment |
|---|---|---|---|---|
| 1 | 61 YR | Required Intervention |