Model Number 419588 |
Device Problem
Difficult to Remove (1528)
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Patient Problems
Renal Failure (2041); Cardiac Tamponade (2226); Cardiac Perforation (2513); Multiple Organ Failure (3261)
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Event Date 06/20/2014 |
Event Type
Death
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Manufacturer Narrative
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The lead has been returned to the manufacturer and analysis is pending.
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Manufacturer Narrative
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Product event summary: the full lead was returned in segments, analyzed and no anomalies were found.Visual summary analysis of the lead indicated apparent explant damage and visual summary analysis of the lead indicated stretching.
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Event Description
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It was reported the patient, who was enrolled in the starfix clinical study, is deceased.The patient presented to the hospital with a one month history of fevers.The device site was found to be swollen and blood cultures were taken and were consistent with enterococcus faecalis septicemia.The patient¿s urine cultures were noted to have grown klebsiella and the patient was noted to have endocarditis.An echocardiogram was performed and noted large vegetation on the tricuspid valve.The patient underwent surgery to remove the device system.The device, right atrial and right ventricle were removed without difficulty.The left ventricular (lv) lead was unable to be removed with traction and a laser sheath was passed over the lead and the lead was removed with difficulty.After removal of the lv lead the patient became hypotensive and the patient was found to have a myocardial laceration and pericardial tamponade.A chest tube was placed and an intraaortic balloon pump was placed.Two epicardial leads were placed and connected to a dual-chamber pacemaker.The patient was taken to the intensive care unit and was treated with antibiotics, inotropes and pressers.The patient developed renal failure requiring dialysis and the sepsis persisted.The patient is reported to have had multisystem organ failure and, after consultation with the family, further treatment was withdrawn and the patient passed away eleven days after system removal.
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Manufacturer Narrative
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This event occurred outside the us where the same model is distributed.All information provided is included in this report.Patient information is not generally available due to confidentiality concerns.The initial reported event was received on (b)(6) 2014.Of note, the serious injury of sepsis is normally submitted via a bimonthly medwatch report submission that would have been due on (b)(6) 2014.Information was subsequently received on (b)(6) 2014 and revealed the patient is deceased.As there is new information that reasonably suggests the device has or may have caused or contributed to a death, this event no longer qualifies for bimonthly reporting and is therefore being submitted as a 30-day report.Concomitant medical products: 694765 lead, implanted: (b)(6) 2010; c174awk icd, implanted: (b)(6) 2010.(b)(4).
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Event Description
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Additional information received reported the patient's blood pressure decreased intraoperative and a pericardial tamponade was suspected.A limited sternotomy was performed and blood was found in the pericardial cavity.The blood was evacuated and the blood pressure stabilized.Upon examination, a tear was observed in the coronary sinus.The tear was sutured and pericardial drains were placed to control the bleeding.An epicardial pacing system was placed and an intra-aortic baloon pump inserted to aid in hemodynamic stability.The study adjudicated the death as related to the lead, extraction procedure and extraction tool.
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Manufacturer Narrative
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If information is provided in the future, a supplemental report will be issued.
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Search Alerts/Recalls
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