Brand Name | FORTIFY ASSURA DR ICD, US |
Type of Device | IMPLANTABLE CARDIOVERTER DEFIBRILLATOR |
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 |
sonali
arangil
|
15900 valley view court |
sylmar, CA 91342
|
|
MDR Report Key | 10861908 |
MDR Text Key | 216913341 |
Report Number | 2017865-2020-17142 |
Device Sequence Number | 1 |
Product Code |
NVZ
|
UDI-Device Identifier | 05414734508094 |
UDI-Public | 05414734508094 |
Combination Product (y/n) | N |
Reporter Country Code | US |
PMA/PMN Number | P910023 |
Number of Events Reported | 1 |
Summary Report (Y/N) | N |
Report Source |
Manufacturer
|
Source Type |
other |
Reporter Occupation |
Non-Healthcare Professional
|
Type of Report
| Initial,Followup |
Report Date |
12/10/2020 |
1 Device was Involved in the Event |
|
1 Patient was Involved in the Event |
|
Is this an Adverse Event Report? |
Yes
|
Is this a Product Problem Report? |
No
|
Device Operator |
Health Professional
|
Device Expiration Date | 03/31/2022 |
Device Model Number | CD2357-40Q |
Device Catalogue Number | CD2357-40Q |
Device Lot Number | A000094634 |
Was Device Available for Evaluation? |
Device Returned to Manufacturer
|
Date Returned to Manufacturer | 10/29/2020 |
Was the Report Sent to FDA? |
No
|
Initial Date Manufacturer Received |
10/29/2020 |
Initial Date FDA Received | 11/18/2020 |
Supplement Dates Manufacturer Received | 11/23/2020
|
Supplement Dates FDA Received | 12/10/2020
|
Was Device Evaluated by Manufacturer? |
Yes
|
Date Device Manufactured | 03/11/2020 |
Is the Device Single Use? |
Yes
|
Is This a Reprocessed and Reused Single-Use Device? |
No
|
Patient Sequence Number | 1 |
Treatment | DURATA STS OPTIM ACTIVE FIXATION, DF-4 CONNECTOR; TENDRIL STS |
Patient Outcome(s) |
Death;
|
Patient Age | 71 YR |