MAUDE Adverse Event Report: AMERICAN MEDICAL SYSTEMS (MN) AMS PERIGEE SYSTEM WITH INTEPRO; SURGICAL MESH

Catalog Number 72404210

Device Problem Insufficient Information (3190)

Patient Problems Breast Cancer (1759); Death (1802); Emotional Changes (1831); Unspecified Infection (1930); Prolapse (2475)

Event Date 07/31/2012

Event Type  Death  

Manufacturer Narrative

This was initially reported on the summary report dated 08/24/2012 under exemption (b)(4).

Event Description

It was reported by the plaintiff's attorney that the plaintiff allegedly experienced infection, bowel problems, and recurrence.Furthermore, it was reported that the plaintiff died.The cause of death was reported as malignant neoplasm breast metastasis.Related to mfr # 2183959-2015-00572, and 2183959-2015-00569.

Event Description

Additional information received indicated that the plaintiff experienced emotional distress and a product problem.

• Brand Name: AMS PERIGEE SYSTEM WITH INTEPRO
• Type of Device: SURGICAL MESH
• Manufacturer (Section D): AMERICAN MEDICAL SYSTEMS (MN); 10700 bren road w; minnetonka MN 55343
• Manufacturer (Section G): AMERICAN MEDICAL SYSTEMS (MN); 10700 bren road w; minnetonka MN 55343
• Manufacturer Contact: erika merrick ; 10700 bren road w; minnetonka, MN 55343 ; 9529306000
• MDR Report Key: 5277809
• MDR Text Key: 33033558
• Report Number: 2183959-2015-00568
• Device Sequence Number: 1
• Product Code: OTP
• Combination Product (y/n): N
• PMA/PMN Number: NA
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: other
• Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date: 07/31/2012

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: 01/25/2008
• Device Catalogue Number: 72404210
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: No
• Initial Date Manufacturer Received: 11/11/2015
• Initial Date FDA Received: 12/09/2015
• Supplement Dates Manufacturer Received: Not provided
• Supplement Dates FDA Received: 02/11/2016
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• Date Device Manufactured: 01/25/2007
• 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): Death
• Patient Age: 60 YR