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

Model Number 407652

Device Problems High impedance (1291); Connection Problem (2900)

Patient Problem Insufficient Information (4580)

Event Date 03/26/2021

Event Type  Injury  

Manufacturer Narrative

Concomitant medical products: product id: 429688 lead, implanted: (b)(6) 2013.If information is provided in the future, a supplemental report will be issued.

Event Description

It was reported that the patient was "not feeling right" two days post cardiac resynchronization therapy pacemaker (crt-p) change.On interrogation it was noted that there was an alert for high and undefined right ventricular (rv) lead impedance.The pocket was reopened and the rv lead was unscrewed from the device and re-inserted.The impedance values returned to normal and the crt-p and rv lead remain in use.No further patient complications have been reported as a result of this event.

• Brand Name: CAPSUREFIX NOVUS MRI SURESCAN
• Type of Device: ELECTRODE, PACEMAKER, PERMANENT
• 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: 11685744
• MDR Text Key: 246021731
• Report Number: 2649622-2021-07656
• Device Sequence Number: 1
• Product Code: DTB
• UDI-Device Identifier: 00885074200682
• UDI-Public: 00885074200682
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: P930039
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: company representative,health
• Reporter Occupation: Physician
• Type of Report: Initial
• Report Date: 04/19/2021

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 04/19/2021
• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: Yes
• Device Operator: Lay User/Patient
• Device Expiration Date: 10/22/2015
• Device Model Number: 407652
• Device Catalogue Number: 407652
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Date Manufacturer Received: 03/27/2021
• Date Device Manufactured: 10/31/2013
• 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: W1TR01 CRT-P, 6725 ADAPTOR
• Patient Outcome(s): Hospitalization; Required Intervention
• Patient Age: 76 YR
• Patient Weight: 53