MAUDE Adverse Event Report: MEDTRONIC, INC. LEAD ADAPTOR KIT; PACEMAKER LEAD ADAPTOR

Model Number	5866-24M
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Unspecified Infection (1930)
Date of Event	10/20/2022
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Concomitant medical products: w1sro1 ipg; implanted: (b)(6) 2021.4968-60 lead; implanted: (b)(6) 2022.If information is provided in the future, a supplemental report will be issued.
Event or Problem Description
It was reported that approximately ten months post implant of the right atrial (ra) lead that the patient experienced an infection.Antibiotics were administered to the patient.The implantable pulse generator (ipg) system was explanted.No further patient complications have been reported as a result of this event.

• Brand Name: LEAD ADAPTOR KIT
• Common Device Name: PACEMAKER LEAD ADAPTOR
• Manufacturer (Section D): MEDTRONIC, INC.; 8200 coral sea street ne; mounds view MN 55112
• Manufacturer (Section G): MEDTRONIC, INC.; 8200 coral sea street ne; mounds view MN 55112
• Manufacturer Contact: paula bixby ; 8200 coral sea st ne; mounds view, MN 55112 ; 7635055378
• MDR Report Key: 15769859
• Report Number: 2182208-2022-03624
• Device Sequence Number: 12384540
• Product Code: DTD
• UDI-Device Identifier: 00681490136785
• UDI-Public: 00681490136785
• Combination Product (Y/N): N
• Initial Reporter State: AZ
• Initial Reporter Country: US
• PMA/510(K) Number: K911302
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2003
• Device Explanted Year: 2022
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Health Professional,Company Representative
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 11/10/2022

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?: No
• Operator of Device: Lay User/Patient
• Device Expiration Date: 07/14/2005
• Device Model Number: 5866-24M
• Device Catalogue Number: 5866-24M
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 10/20/2022
• Initial Report FDA Received Date: 11/10/2022
• Date Device Manufactured: 07/24/2003
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Initial
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: 4951M-20 LEAD, 4951M-20 LEAD
• Outcome Attributed to Adverse Event: Hospitalization; Required Intervention
• Patient Age: 34 YR
• Patient Sex: Male