MAUDE Adverse Event Report: ST. JUDE MEDICAL INC., CARDIAC RHYTHM MANAGEMENT D PROMOTE RF CRT-D

Model Number 3213-36

Device Problems Failure to Convert Rhythm (1540); Therapeutic or Diagnostic Output Failure (3023)

Patient Problem No Known Impact Or Consequence To Patient (2692)

Event Date 04/20/2012

Event Type  malfunction  

Event Description

It was reported that the patient had appropriate shocks for a fast vt which did not convert the rhythm.Dft testing was performed and the device failed to convert the patient.The device was reprogrammed.

Manufacturer Narrative

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.

• Brand Name: PROMOTE RF CRT-D
• Manufacturer (Section D): ST. JUDE MEDICAL INC., CARDIAC RHYTHM MANAGEMENT D; 15900 valley view ct; sylmar CA 91342
• Manufacturer (Section G): ST. JUDE MEDICAL INC., CARDIAC RHYTHM MANAGEMENT D; 15900 valley view ct; sylmar CA 91342
• Manufacturer Contact: cary lawler ; 15900 valley view ct; sylmar, CA 91342 ; 8184932621
• MDR Report Key: 3880446
• MDR Text Key: 4508942
• Report Number: 2938836-2014-03511
• Device Sequence Number: 1
• Product Code: NIK
• Combination Product (y/n): N
• PMA/PMN Number: NA
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Foreign,Health Professional,User Facility,Company Representative
• Reporter Occupation: Physician
• Type of Report: Initial

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 01/13/2014
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Expiration Date: 09/30/2009
• Device Model Number: 3213-36
• Device Catalogue Number: SMTFY999
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Distributor Facility Aware Date: 04/20/2012
• Device Age: 44 MO
• Event Location: Hospital
• Date Manufacturer Received: 04/26/2012
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• Date Device Manufactured: 09/01/2008
• 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