BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    QUICKSITE LV

    MDR report key: 4190187 · Received January 11, 2014

    Report

    Report Number
    2017865-2014-02208
    Event Type
    Malfunction
    Date Received
    January 11, 2014
    Date of Event
    August 30, 2011
    Manufacturer
    ST. JUDE MEDICAL, CRMD
    Product Code
    NIK
    PMA / PMN Number
    P030054
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    GA, 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.

    Description of Event or Problem · 1

    IT WAS REPORTED THAT THE PT EXPERIENCED PHRENIC NERVE STIMULATION. THE LEFT VENTRICULAR LEAD WAS DEACTIVATED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    21717 QUICKSITE LV PERMANENT PACEMAKER ELECTRODE NIK ST. JUDE MEDICAL, CRMD 1056T/75

    Patients

    Seq Age Sex Outcome Treatment
    1 66 YR