MAUDE Adverse Event Report: MEDTRONIC, INC. EPSILA EV¿; PERMANENT DEFIBRILLATOR ELECTRODES

Model Number	EAZ101
Medical Device Problem Code	Appropriate Device Problem Term/Code Not Available (3191)
Health Effect - Clinical Code	Pain (1994)
Date of Event	05/15/2024
Type of Reportable Event	Serious Injury
Event or Problem Description
It was reported that post implant of the the patient's extravascular implantable cardioverter defibrillator (ev-icd) system and with use of the sternal tunneling tool the patient experienced ongoing substernal and lateral mid-axilla pocket site pain.The patient required ongoing medication for pain relief, including paracetamol, tramadol, and ibuprofen.The pain prolonged the patient's hospitalization.The device remains in use. no further patient complications have been reported as a result of this event.The patient is a participant in a clinical study.
Additional Manufacturer Narrative
Continuation of d10: product id dvea3e4, serial# (b)(6), implanted: (b)(6) 2024.Medtronic submits this report to comply with fda regulations 21 cfr parts 4 and 803.Medtronic has made reasonable efforts to provide as much relevant information as is available to the company as of the submission date of this report.This report does not constitute an admission or a conclusion by fda, medtronic, or its employees that the device, medtronic, or its employee caused or contributed to the event described in the report.Any required fields that are unpopulated are blank because the information is currently unknown or unavailable.Medtronic will submit a supplemental report if additional relevant information becomes known.

• Brand Name: EPSILA EV¿
• Common Device Name: PERMANENT DEFIBRILLATOR ELECTRODES
• 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: gerard torenvliet ; 8200 coral sea st ne; mounds view, MN 55112 ; 7635269277
• MDR Report Key: 19571095
• Report Number: 9614453-2024-02364
• Device Sequence Number: 4057703
• Product Code: NVY
• UDI-Device Identifier: 00763000369736
• UDI-Public: 00763000369736
• Combination Product (Y/N): N
• Initial Reporter Country: NZ
• PMA/510(K) Number: P220012
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Foreign,Study,Health Professional
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 06/19/2024

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: 08/24/2025
• Device Model Number: EAZ101
• Device Catalogue Number: EAZ101
• Device Lot Number: 102423723
• 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: 05/22/2024
• Initial Report FDA Received Date: 06/19/2024
• Date Device Manufactured: 08/25/2023
• 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
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: EV2401-63 LEAD.
• Outcome Attributed to Adverse Event: Hospitalization; Required Intervention
• Patient Sex: Female
• Patient Weight: 64 KG