MAUDE Adverse Event Report: ASTORA WOMEN'S HEALTH LLC AMS PERIGEE SYSTEM; SURGICAL MESH

Catalog Number 720003-01

Device Problem Insufficient Information (3190)

Patient Problems Death (1802); Micturition Urgency (1871); Incontinence (1928); Unspecified Infection (1930); Inflammation (1932); Myocardial Infarction (1969); Pain (1994); Scarring (2061); Urinary Retention (2119); Urinary Tract Infection (2120); Urinary Frequency (2275); Prolapse (2475); Sleep Dysfunction (2517); Blood Loss (2597)

Event Date 03/03/2014

Event Type  Death  

Manufacturer Narrative

This was initially reported on the summary report dated 06/30/2014 under (b)(4).

Event Description

It was reported by the plaintiff's attorney that the plaintiff allegedly experienced pain, infection, urinary problems, bowel problems, recurrence, bleeding, dyspareunia and vaginal scarring.It was also reported that the plaintiff experienced overactive bladder, worsening, urgency, frequency, nocturia, incomplete bladder emptying, irritative voiding symptoms, urinary tract infections, acute cystitis, and back pain.Furthermore, it was reported that the plaintiff died.The causes of death were reported as acute myocardial infarction and coronary artery disease.Related to manufacturer report #: 3011770902-2016-00355, 3011770902-2016-00357, 3011770902-2016-00356.

• Brand Name: AMS PERIGEE SYSTEM
• Type of Device: SURGICAL MESH
• Manufacturer (Section D): ASTORA WOMEN'S HEALTH LLC; 13200 pioneer trail; suite 100; eden prairie MN 55347
• Manufacturer (Section G): ASTORA WOMEN'S HEALTH LLC; 13200 pioneer trail; suite 100; eden prairie MN 55347
• Manufacturer Contact: randy hoyt ; 13200 pioneer trail; suite 100; eden prairie, MN 55347 ; 9522383906
• MDR Report Key: 5909899
• MDR Text Key: 53315048
• Report Number: 3011770902-2016-00354
• Device Sequence Number: 1
• Product Code: OTP
• 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: other
• Reporter Occupation: Other
• Type of Report: Initial
• Report Date: 04/24/2013

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: 03/07/2009
• Device Catalogue Number: 720003-01
• Was Device Available for Evaluation?: No
• Initial Date Manufacturer Received: 08/17/2016
• Initial Date FDA Received: 08/29/2016
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• Date Device Manufactured: 03/20/2008
• 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
• Treatment: MIINIARC
• Patient Outcome(s): Death
• Patient Age: 80 YR
• Patient Weight: 59