MAUDE Adverse Event Report: MPRI ATTAIN ABILITY PLUS MRI SURESCAN; DRUG ELUTING PERMANENT LEFT VENTRICULAR (LV) P

Model Number 429688

Device Problem Appropriate Term/Code Not Available (3191)

Patient Problems Bacterial Infection (1735); Fever (1858); Low Blood Pressure/ Hypotension (1914); Muscle Weakness (1967); Septic Shock (2068)

Event Date 06/24/2022

Event Type  Death  

Event Description

It was reported that the patient experienced dark discoloration at the cardiac resynchronization therapy defibrillator (crt-d) device site and bloody drainage.Six days later, the patient was seen in clinic, x-ray revealed half inch open area along incision line oozing, blood cultures taken were negative and patient started on antibiotics.Follow up scheduled, however the patient cancelled the follow up appointment.Approximately, two weeks later the patient contacted the clinic via phone and reported site still oozing.Two days later, the patient presented to the hospital for progressive weakness, febrile, elevated troponin, elevated d dimer, possible pneumonia.The patient was transported to a second hospital with noted hypotensive condition.The patient was admitted to the intensive care unit (icu) with concern for sepsis, noted fluid pocket around the crt-d device site and right empyema.The patient was intubated, vasopressor support administered, and crt-d detections were deactivated.An infection was noted at the crt-d device site.Cultures were performed, the organism was identified as methicillin sensitive staph aureus (mssa), and the patient developed septic shock.The patient family elected for comfort care and the patient passed away the following day.The patient is a participant in a clinical study.

Manufacturer Narrative

Concomitant medical products: dtma1d1 crt-d implanted: on (b)(6) 2019 3830 lead, cmrm6133 envelope implanted: on (b)(6) 2022 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: ATTAIN ABILITY PLUS MRI SURESCAN
• Type of Device: DRUG ELUTING PERMANENT LEFT VENTRICULAR (LV) P
• Manufacturer (Section D): MPRI; road 149 km 56.3; villalba PR 00766
• Manufacturer (Section G): MPRI; road 149 km 56.3; villalba PR 00766
• Manufacturer Contact: paula bixby ; 8200 coral sea st ne; mounds view, MN 55112 ; 7635055378
• MDR Report Key: 16164938
• MDR Text Key: 307453117
• Report Number: 2649622-2023-01223
• Device Sequence Number: 1
• Product Code: OJX
• UDI-Device Identifier: 00613994719133
• UDI-Public: 00613994719133
• Combination Product (y/n): Y
• Reporter Country Code: US
• PMA/PMN Number: P080006
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Study,Health Professional,Company Representative
• Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date: 01/13/2023

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 01/13/2023
• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Device Operator: Lay User/Patient
• Device Expiration Date: 09/16/2013
• Device Model Number: 429688
• Device Catalogue Number: 429688
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Date Manufacturer Received: 12/19/2022
• Date Device Manufactured: 11/01/2011
• Is the Device Single Use?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Initial
• Patient Sequence Number: 1
• Treatment: 457445 LEAD, 694958 LEAD.
• Patient Outcome(s): Life Threatening; Required Intervention; Hospitalization; Death
• Patient Age: 73 YR
• Patient Sex: Male
• Patient Weight: 98 KG
• Patient Ethnicity: Hispanic
• Patient Race: White