BEUDAMED
    FDA Adverse Event Injury Summary report: N

    FORTIFY DR

    MDR report key: 4160793 · Received January 13, 2014

    Report

    Report Number
    2938836-2014-01871
    Event Type
    Injury
    Date Received
    January 13, 2014
    Date of Event
    November 12, 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
    MD, US
    Reporter Occupation
    PHYSICIAN

    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 A PT RECEIVED AN INAPPROPRIATE HIGH VOLTAGE THERAPY DUE TO THE AV INTERVAL DELTA DIAGNOSING A RHYTHM AS VT WHEN THE PT WAS IN A STABLE SUPRAVENTRICULAR TACHYCARDIA RHYTHM. THE DEVICE WAS REPROGRAMMED AND THE PT WILL BE CONTINUE TO BE MONITORED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    26606 FORTIFY DR IMPLANTABLE CARDIOVERTER DEFIBRILLATOR LWS ST. JUDE MEDICAL INC. CRMD CD2231-40

    Patients

    Seq Age Sex Outcome Treatment
    1 27 YR Required Intervention