BEUDAMED
    FDA Adverse Event Injury Summary report: N

    CAPSUREFIX MRI SURESCAN

    MDR report key: 4162593 · Received October 10, 2014

    Report

    Report Number
    2649622-2014-12696
    Event Type
    Injury
    Date Received
    October 10, 2014
    Date of Event
    July 23, 2014
    Report Date
    August 14, 2014
    Manufacturer
    MPRI
    Product Code
    NVN
    PMA / PMN Number
    P090013
    Adverse Event
    Yes
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    NY, US
    Reporter Occupation
    OTHER

    Narratives

    Additional Manufacturer Narrative · 1

    THE INFORMATION SUBMITTED REFLECTS ALL RELEVANT DATA RECEIVED. IF ADDITIONAL RELEVANT INFORMATION IS RECEIVED, A SUPPLEMENTAL REPORT WILL BE SUBMITTED. (B)(4).

    Description of Event or Problem · 1

    IT WAS REPORTED BY THE PATIENT THAT ONE OF THEIR LEADS WAS NOT WORKING AND NEEDED TO BE RE-DONE. FOLLOW-UP INFORMATION FROM THE CLINIC INDICATES THAT AT THE TWO-WEEK POST-OPERATIVE CHECK IT WAS NOTED THAT THE RIGHT VENTRICULAR (RV) LEAD HAD DIMINISHED SENSING AND WAS FOUND TO BE DISLODGED. THE LEAD WAS REPOSITIONED AND REMAINS IN USE. NO PATIENT COMPLICATIONS HAVE BEEN REPORTED AS A RESULT OF THIS EVENT.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    643749 CAPSUREFIX MRI SURESCAN DRUG ELUTING PERMANENT RIGHT VENTRICULAR (RV) OR RIGHT ATRIAL (RA) PACEMAKER ELE NVN MPRI 5086MRI52

    Patients

    Seq Age Sex Outcome Treatment
    1 00076 YR Hospitalization| R 5086MRI45 LEAD, A2DR01 IPG