MAUDE Adverse Event Report: MEDTRONIC SINGAPORE OPERATIONS ADVISA MRI SURESCAN; PULSE GENERATOR, PERMANENT, IMPLANTABLE

Model Number A3DR01

Device Problems Failure to Capture (1081); Capturing Problem (2891); High Capture Threshold (3266)

Patient Problems Bradycardia (1751); Loss of consciousness (2418); Syncope/Fainting (4411)

Event Date 08/27/2021

Event Type  malfunction  

Manufacturer Narrative

Concomitant medical products: mdt-lead, implant date: unknown.If information is provided in the future, a supplemental report will be issued.

Event Description

It was reported that the patient experienced bradycardia, loss of consciousness secondary to fainting and left sided venous occlusion.It was also reported that the right ventricular (rv) lead and implantable pulse generator (ipg) exhibited increased threshold, high threshold, pacing failure mediated at the myocardial end.Both the rv lead and ipg were initially reprogrammed.Subsequently, both the rv lead and right atrial (ra) lead were capped and the ipg was explanted.Both the rv lead and the ipg were replaced on the contralateral side.No further patient complications have been reported as a result of this event.

Manufacturer Narrative

Corrected: d10.Medtronic is submitting this report to comply with fda reporting regulations under 21 cfr parts 4 and 803.This report is based upon information obtained by medtronic, which the company may not have been able to fully investigate or verify prior to the date the report was required by the fda.Medtronic has made reasonable efforts to obtain more complete information and has provided as much relevant information as is available to the company as of the submission date of this report.This report does not constitute an admission or a conclusion by fda, medtronic, or its employees that the device, medtronic, or its employee caused or contributed to the event described in the report.In particular, this report does not constitute an admission by anyone that the product described in this report has any ¿defects¿ or has ¿malfunctioned¿.These words are included in the fda 3500a form and are fixed items for selection created by the fda to categorize the type of event solely for the purpose of regulatory reporting.Medtronic objects to the use of these words and others like them because of the lack of definition and the connotations implied by these terms.This statement should be included with any information or report disclosed to the public under the freedom of information act.Any required fields that are unpopulated are blank because the information is currently unknown or unavailable.A good faith effort will be made to obtain the applicable information relevant to the report.If information is provided in the future, a supplemental report will be issued.

• Brand Name: ADVISA MRI SURESCAN
• Type of Device: PULSE GENERATOR, PERMANENT, IMPLANTABLE
• Manufacturer (Section D): MEDTRONIC SINGAPORE OPERATIONS; 49 changi south avenue 2; nasaco tech centre; singapore 48605 6; SN 486056
• MDR Report Key: 12472978
• MDR Text Key: 271452819
• Report Number: 3008973940-2021-03333
• Device Sequence Number: 1
• Product Code: NVZ
• Combination Product (y/n): N
• PMA/PMN Number: P980035
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: company representative,foreig
• Type of Report: Initial,Followup
• Report Date: 09/15/2021

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?: Yes
• Device Operator: Lay User/Patient
• Device Expiration Date: 12/28/2019
• Device Model Number: A3DR01
• Device Catalogue Number: A3DR01
• Was Device Available for Evaluation?: No
• Initial Date Manufacturer Received: 09/15/2021
• Initial Date FDA Received: 09/15/2021
• Supplement Dates Manufacturer Received: 09/15/2021
• Supplement Dates FDA Received: 09/15/2021
• Is This a Reprocessed and Reused Single-Use Device?: No
• Patient Sequence Number: 1
• Treatment: 5076-58; 5076-58 LEAD; 5076-58; 5076-58 LEAD
• Patient Outcome(s): Hospitalization; Required Intervention
• Patient Age: 81 YR