Brand Name | AMPLIA MRI QUAD CRT-D SURESCAN |
Type of Device | DEFIBRILLATOR, AUTOMATIC IMPLANTABLE CARDIOVERTER, WITH CARDIAC RESYNCHRONIZATIO |
Manufacturer (Section D) |
MEDTRONIC PUERTO RICO OPERATIONS CO. |
road 31, km. 24, hm 4 |
ceiba norte industrial park |
juncos PR 00777 |
|
Manufacturer (Section G) |
MEDTRONIC PUERTO RICO OPERATIONS CO. |
road 31, km. 24, hm 4 |
ceiba norte industrial park |
juncos PR 00777 |
|
Manufacturer Contact |
paula
bixby
|
8200 coral sea st ne |
mounds view, MN 55112
|
7635055378
|
|
MDR Report Key | 14744285 |
MDR Text Key | 294500727 |
Report Number | 3004209178-2022-07850 |
Device Sequence Number | 1 |
Product Code |
NIK
|
UDI-Device Identifier | 00643169543386 |
UDI-Public | 00643169543386 |
Combination Product (y/n) | N |
Reporter Country Code | US |
PMA/PMN Number | P010031 |
Number of Events Reported | 1 |
Summary Report (Y/N) | N |
Report Source |
Manufacturer
|
Source Type |
Study,Health Professional,Company Representative |
Reporter Occupation |
Physician
|
Type of Report
| Initial |
Report Date |
06/20/2022 |
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 | 02/28/2018 |
Device Model Number | DTMB1QQ |
Device Catalogue Number | DTMB1QQ |
Was Device Available for Evaluation? |
No
|
Is the Reporter a Health Professional? |
Yes
|
Initial Date Manufacturer Received |
05/24/2022 |
Initial Date FDA Received | 06/20/2022 |
Date Device Manufactured | 09/01/2016 |
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 | 429888 LEAD, 5076-52 LEAD, 6935M62 LEAD |
Patient Outcome(s) |
Required Intervention;
|
Patient Age | 79 YR |
Patient Sex | Male |
Patient Weight | 77 KG |
|
|