Brand Name | GALLANT DR |
Type of Device | NO MATCH |
Manufacturer (Section D) |
ST. JUDE MEDICAL, INC.(CRM-SYLMAR) |
15900 valley view court |
sylmar CA 91342 |
|
Manufacturer (Section G) |
ST. JUDE MEDICAL, INC.(CRM-SYLMAR) |
15900 valley view court |
|
sylmar CA 91342 |
|
Manufacturer Contact |
richard
williamson
|
15900 valley view court |
sylmar, CA 91342
|
|
MDR Report Key | 19112318 |
MDR Text Key | 340460719 |
Report Number | 2017865-2024-38458 |
Device Sequence Number | 1 |
Product Code |
NIK
|
UDI-Device Identifier | 05415067032003 |
UDI-Public | (01)05415067032003(10)P000168414(17)250331 |
Combination Product (y/n) | N |
Reporter Country Code | US |
PMA/PMN Number | P030054 |
Number of Events Reported | 1 |
Summary Report (Y/N) | N |
Report Source |
Manufacturer
|
Source Type |
Health Professional,User Facility,Company Representative |
Reporter Occupation |
Physician
|
Type of Report
| Initial,Followup,Followup |
Report Date |
05/01/2024 |
1 Device was Involved in the Event |
|
1 Patient was Involved in the Event |
|
Is this an Adverse Event Report? |
No
|
Is this a Product Problem Report? |
Yes
|
Device Operator |
Health Professional
|
Device Model Number | CDDRA500Q |
Device Lot Number | P000168414 |
Was Device Available for Evaluation? |
No
|
Is the Reporter a Health Professional? |
Yes
|
Was the Report Sent to FDA? |
No
|
Initial Date Manufacturer Received |
03/27/2024
|
Initial Date FDA Received | 04/15/2024 |
Supplement Dates Manufacturer Received | 04/16/2024 05/01/2024
|
Supplement Dates FDA Received | 04/18/2024 05/01/2024
|
Was Device Evaluated by Manufacturer? |
No
|
Date Device Manufactured | 04/19/2023 |
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 | 2088TC/46 TENDRIL STSLEADS; 7122Q/52 DURATALEADS; APP1004 MYMERLIN APPLICATION |
Patient Age | 85 YR |
Patient Sex | Male |