Brand Name | FORTIFY ASSURA DR ICD, US |
Type of Device | IMPLANTABLE CARDIOVERTER DEFIBRILLATOR |
Manufacturer (Section D) |
ST. JUDE MEDICAL, INC.(CRM-SYLMAR) |
15900 valley view court |
sylmar CA 91342 |
|
Manufacturer (Section G) |
ST. JUDE MEDICAL, INC.(CRM-SYLMAR) |
15900 valley view court |
|
sylmar CA 91342 |
|
Manufacturer Contact |
elizabeth
boltz
|
15900 valley view court |
sylmar, CA 91342
|
8184932577
|
|
MDR Report Key | 8204004 |
MDR Text Key | 131645370 |
Report Number | 2017865-2018-19738 |
Device Sequence Number | 1 |
Product Code |
NVZ
|
UDI-Device Identifier | 05414734508094 |
UDI-Public | 05414734508094 |
Combination Product (y/n) | N |
Reporter Country Code | US |
PMA/PMN Number | P910023 |
Number of Events Reported | 1 |
Summary Report (Y/N) | N |
Report Source |
Manufacturer
|
Source Type |
company representative,health |
Reporter Occupation |
Physician
|
Type of Report
| Initial |
Report Date |
12/28/2018 |
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? |
No
|
Device Operator |
Health Professional
|
Device Expiration Date | 03/31/2016 |
Device Model Number | CD2357-40Q |
Device Lot Number | 4535750 |
Was Device Available for Evaluation? |
No
|
Is the Reporter a Health Professional? |
Yes
|
Was the Report Sent to FDA? |
No
|
Initial Date Manufacturer Received |
12/18/2018 |
Initial Date FDA Received | 12/28/2018 |
Was Device Evaluated by Manufacturer? |
Device Not Returned to Manufacturer
|
Date Device Manufactured | 03/26/2014 |
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 | 1688TC/52, (B)(4); LDA210Q/65, (B)(4) |
Patient Outcome(s) |
Required Intervention;
|