MAUDE Adverse Event Report: MPRI CAPSUREFIX NOVUS LEAD MRI SURESCAN; ELECTRODE, PACEMAKER, PERMANENT

Model Number 5076-52

Device Problems Signal Artifact/Noise (1036); Intermittent Capture (1080); Fracture (1260); Connection Problem (2900); Impedance Problem (2950)

Patient Problem No Consequences Or Impact To Patient (2199)

Event Date 08/31/2020

Event Type  Injury  

Manufacturer Narrative

Concomitant medical products: ddmb1d1, icd, implanted: (b)(6) 2020.If information is provided in the future, a supplemental report will be issued.

Event Description

It was reported that after an implantable cardioverter defibrillator (icd) change out procedure the right atrial (ra) lead showed increased pacing impedance and baseline noise.Upon evaluation of an x-ray, it was indicated that there was evidence of an ra lead/icd connection issue.The ra lead and icd remain in use.No patient complications have been reported as a result of this event.

Event Description

It was further reported that the patient was brought to the lab to open the device pocket for evaluation.The right atrial (ra) lead pin appeared fully inserted into the device and the setscrew of the device was tightened appropriately and locked into place.The atrial lead was disconnected from the device and measured through an analyzer under bipolar configuration, revealing atrial noise, variable impedance and intermittent capture.A ring electrode fracture was suspected and the lead was capped and replaced.The implantable cardioverter defibrillator (icd) remains in use.No patient complications have been reported as a result of this event.

Manufacturer Narrative

Medtronic is submitting this report to comply with fda reporting regulations under 21 cfr parts 4 and 803.This report is based upon information obtained by medtronic, which the company may not have been able to fully investigate or verify prior to the date the report was required by the fda.Medtronic has made reasonable efforts to obtain more complete information and has provided as much relevant information as is available to the company as of the submission date of this report.This report does not constitute an admission or a conclusion by fda, medtronic, or its employees that the device, medtronic, or its employee caused or contributed to the event described in the report.In particular, this report does not constitute an admission by anyone that the product described in this report has any ¿defects¿ or has ¿malfunctioned¿.These words are included in the fda 3500a form and are fixed items for selection created by the fda to categorize the type of event solely for the purpose of regulatory reporting.Medtronic objects to the use of these words and others like them because of the lack of definition and the connotations implied by these terms.This statement should be included with any information or report disclosed to the public under the freedom of information act.Any required fields that are unpopulated are blank because the information is currently unknown or unavailable.A good faith effort will be made to obtain the applicable information relevant to the report.If information is provided in the future, a supplemental report will be issued.

• Brand Name: CAPSUREFIX NOVUS LEAD MRI SURESCAN
• Type of Device: ELECTRODE, PACEMAKER, PERMANENT
• Manufacturer (Section D): MPRI; road 149 km 56.3; villalba PR 00766
• MDR Report Key: 10785874
• MDR Text Key: 214580754
• Report Number: 2649622-2020-21408
• Device Sequence Number: 1
• Product Code: DTB
• UDI-Device Identifier: 00681490124812
• UDI-Public: 00681490124812
• Combination Product (y/n): N
• PMA/PMN Number: P930039
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: company representative
• Type of Report: Initial,Followup
• Report Date: 11/10/2020

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: Yes
• Device Operator: Lay User/Patient
• Device Expiration Date: 08/20/2010
• Device Model Number: 5076-52
• Device Catalogue Number: 5076-52
• Was Device Available for Evaluation?: No
• Initial Date Manufacturer Received: 10/21/2020
• Initial Date FDA Received: 11/04/2020
• Supplement Dates Manufacturer Received: 11/06/2020
• Supplement Dates FDA Received: 11/10/2020
• Is This a Reprocessed and Reused Single-Use Device?: No
• Patient Sequence Number: 1
• Treatment: 0181 LEAD; 0181 LEAD
• Patient Outcome(s): Hospitalization; Required Intervention
• Patient Age: 51 YR