MAUDE Adverse Event Report: ST. JUDE MEDICAL, CRMD IDENTIFY ADX XL DR; IMPLANTABLE PACEMAKER PULSE GENERATOR, DXY

Model Number 5386

Device Problem No Device Output (1435)

Patient Problem Cardiac Arrest (1762)

Event Date 04/12/2012

Event Type  malfunction  

Event Description

It was reported that during device change out due to normal battery depletion the device came into contact with electrocautery and exhibited a loss of output resulting in asystole and the need for external defibrillation.The explant procedure was completed and the device was replaced.

Manufacturer Narrative

All information provided by manufacturer, no medwatch form was received.This historical complaint is being filed as part of a retrospective review of complaint files in response to a recent fda inspection.There is no change to the actual performance of the product and this report represents an enhancement to the reporting criteria going forward.

• Brand Name: IDENTIFY ADX XL DR
• Type of Device: IMPLANTABLE PACEMAKER PULSE GENERATOR, DXY
• Manufacturer (Section D): ST. JUDE MEDICAL, CRMD; 15900 valley view court; sylmar CA 91342
• Manufacturer (Section G): ST. JUDE MEDICAL, INC., CRMD; 15900 valley view court; sylmar CA 91342
• Manufacturer Contact: cary lawler ; 15900 valley view court; sylmar, CA 91342 ; 8184932621
• MDR Report Key: 4121584
• MDR Text Key: 4919179
• Report Number: 2017865-2014-07741
• Device Sequence Number: 1
• Product Code: DXY
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: NA
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Company Representative
• Reporter Occupation: Other
• Type of Report: Initial

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Expiration Date: 02/28/2005
• Device Model Number: 5386
• Device Catalogue Number: SMTFY999
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: No
• Distributor Facility Aware Date: 04/12/2012
• Device Age: 9 YR
• Event Location: Hospital
• Initial Date Manufacturer Received: 04/12/2012
• Initial Date FDA Received: 01/13/2014
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• Date Device Manufactured: 08/01/2003
• Is the Device Single Use?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: No
• Patient Sequence Number: 1
• Patient Age: 87 YR