MAUDE Adverse Event Report: BOSTON SCIENTIFIC CORPORATION ACCOLADE MRI DR; IMPLANTABLE PULSE GENERATOR, PACEMAKER (NON-CRT)

Model Number L311

Device Problems Pacing Problem (1439); Incorrect, Inadequate or Imprecise Result or Readings (1535); Battery Problem (2885); Inappropriate or Unexpected Reset (2959)

Patient Problems Fall (1848); Head Injury (1879); Hematoma (1884); Loss of consciousness (2418); Syncope/Fainting (4411); Asystole (4442)

Event Date 09/13/2023

Event Type  Injury  

Event Description

It was reported that this patient implanted with this pacemaker system was seen by neurosurgery for emergency treatment due to epidural hematoma after a patient fall and loss of consciousness.A device check revealed that the pacemaker was in safety mode, and external telemetry showed prolonged heart rate intervals with no visible pacing spikes.Additionally, it was suspected that the battery of this pacemaker had depleted prematurely as a longevity calculation from three months prior showed approximately 9 months remaining.This pacemaker was explanted, replaced, and shipped for return analysis.No additional adverse patient effects were reported.

Manufacturer Narrative

If pertinent information is provided in the future, a supplemental report will be submitted.

Manufacturer Narrative

Correction to h10: updated to include analysis findings.Upon receipt at our post market quality assurance laboratory, this device was thoroughly inspected and analyzed.Device telemetry data confirmed it was operating in safety mode and had undergone resets.Engineers determined that this device was demonstrating behavior consistent with a high internal cell impedance within the battery.The high internal impedance put this device at risk of experiencing transient voltage decreases (and associated resets) during periods of high-power consumption.When battery voltage drops below a minimum threshold, a system reset is performed.If three system resets occur within a 48-hour period, the device is designed to immediately enter safety mode operation to maintain back-up pacing with pre-defined, non-programmable settings.

Event Description

It was reported that this patient implanted with this pacemaker system was seen by neurosurgery for emergency treatment due to epidural hematoma after a patient fall and loss of consciousness.A device check revealed that the pacemaker was in safety mode, and external telemetry showed prolonged heart rate intervals with no visible pacing spikes.Additionally, it was suspected that the battery of this pacemaker had depleted prematurely as a longevity calculation from three months prior showed approximately 9 months remaining.This pacemaker was explanted, replaced, and shipped for return analysis.No additional adverse patient effects were reported.

• Brand Name: ACCOLADE MRI DR
• Type of Device: IMPLANTABLE PULSE GENERATOR, PACEMAKER (NON-CRT)
• Manufacturer (Section D): BOSTON SCIENTIFIC CORPORATION; 4100 hamline avenue north; saint paul MN 55112
• Manufacturer (Section G): BOSTON SCIENTIFIC CORPORATION; cashel road; clonmel ; EI
• Manufacturer Contact: timothy degroot ; 4100 hamline avenue north; saint paul, MN 55112 ; 6515826168
• MDR Report Key: 17857605
• MDR Text Key: 324764433
• Report Number: 2124215-2023-54196
• Device Sequence Number: 1
• Product Code: LWP
• Combination Product (y/n): N
• Reporter Country Code: JA
• PMA/PMN Number: P150012/S000
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Other,Foreign,Health Professional,Company Representative
• Reporter Occupation: Physician
• Remedial Action: Replace
• Type of Report: Initial,Followup
• Report Date: 02/01/2024

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: 07/06/2018
• Device Model Number: L311
• Device Catalogue Number: L311
• Device Lot Number: 239832
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Is the Reporter a Health Professional?: Yes
• Initial Date Manufacturer Received: 09/14/2023
• Initial Date FDA Received: 10/02/2023
• Supplement Dates Manufacturer Received: 11/30/2023
• Supplement Dates FDA Received: 02/01/2024
• Was Device Evaluated by Manufacturer?: Yes
• Date Device Manufactured: 07/19/2016
• 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
• Patient Outcome(s): Hospitalization; Required Intervention