MAUDE Adverse Event Report: BIOTRONIK SE & CO. KG RIVACOR 5 HF-T DF4 IS-1 PROMRI; ICD

Model Number	429562
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Codes	Hematoma (1884); Unspecified Infection (1930)
Date of Event	06/26/2020
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
An infection was observed following the implantation of this biotronik device.The sterilization process was investigated.The validated process assures that all sterilization parameters, such as gas concentration, temperature, humidity, etc., are within its specified ranges for each distributed device.Additional an analysis of validated microbiological indicators is performed after every sterilization procedure as evidence of successful completion of the sterilization process.Review of the biotronik complaint database did not reveal any changes regarding the trend for this type of incident.In summary, the infection was not device related.
Event or Problem Description
After crt-d implantation, the patient had pocket hematoma.Crp and leukocytes were increased and potassium was decreased, gram negative bacteria were detected.The patient was hospitalized, receives piperazillin and tazobactam and potassium.Furthermore a revision of hematoma was done on (b)(6) 2020.For diagnostic reasons the patient got blood cultures.Patient was discharged in a good health condition.

• Brand Name: RIVACOR 5 HF-T DF4 IS-1 PROMRI
• Common Device Name: ICD
• Manufacturer (Section D): BIOTRONIK SE & CO. KG; woermannkehre 1; berlin 12359 ; DE 12359
• MDR Report Key: 10311528
• Report Number: 1028232-2020-03016
• Device Sequence Number: 16993824
• Product Code: NIK
• UDI-Device Identifier: 04035479156886
• UDI-Public: 04035479156886
• Combination Product (Y/N): N
• Initial Reporter Country: DE
• PMA/510(K) Number: P050023
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2020
• Reporter Type: Manufacturer
• Report Source: company representative,foreig
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 07/14/2020

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
• Operator of Device: Health Professional
• Device Expiration Date: 02/28/2021
• Device Model Number: 429562
• Device Catalogue Number: SEE MODEL NO.
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 07/21/2020
• Initial Report FDA Received Date: 07/22/2020
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Hospitalization