MAUDE Adverse Event Report: BOSTON SCIENTIFIC CORPORATION ENDOTAK RELIANCE; IMPLANTABLE LEAD

Model Number	0157
Medical Device Problem Codes	Defective Device (2588); Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	08/20/2024
Type of Reportable Event	Serious Injury
Event or Problem Description
It was reported that this right ventricular (rv) lead pace/sense part was surgically capped.Furthermore, the other rv lead was used for pacing and sensing.This lead remains implanted.No additional adverse patient effects were reported.
Additional Manufacturer Narrative
Correction to field f10.Device codes.
Event or Problem Description
It was reported that this right ventricular (rv) lead pace/sense part was surgically capped.Furthermore, the other rv lead was used for pacing and sensing.This lead remains implanted.No additional adverse patient effects were reported.Additional information received from the field indicating that this lead pace/sense part was surgically abandoned as this is a standard operating procedure for this electrophysiology at upgrades.
Event or Problem Description
It was reported that this right ventricular (rv) lead pace/sense part was surgically capped.Furthermore, the other rv lead was used for pacing and sensing.This lead remains implanted.No additional adverse patient effects were reported.Additional information received from the field indicating that this lead pace/sense part was surgically abandoned as this is a standard operating procedure for this electrophysiology at upgrades.
Additional Manufacturer Narrative
Correction to field f10.Device codes.This supplemental correction report was created to capture updates on d2a: common device name.

• Brand Name: ENDOTAK RELIANCE
• Common Device Name: IMPLANTABLE LEAD
• Manufacturer (Section D): BOSTON SCIENTIFIC CORPORATION; 4100 hamline avenue north; saint paul MN 55112
• Manufacturer (Section G): BOSTON SCIENTIFIC CORPORATION; road 698, lot no. 12; dorado PR 00646 -260; * 00646-2602
• Manufacturer Contact: timothy degroot ; 4100 hamline avenue north; saint paul, MN 55112 ; 6515826168
• MDR Report Key: 20244731
• Report Number: 2124215-2024-58255
• Device Sequence Number: 15276845
• Product Code: LWS
• UDI-Device Identifier: 00802526531125
• UDI-Public: 00802526531125
• Combination Product (Y/N): Y
• Initial Reporter State: AR
• Initial Reporter Country: US
• PMA/510(K) Number: P910073/S039
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2024
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Health Professional,Company Representative
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 04/15/2026

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
• Operator of Device: Lay User/Patient
• Device Expiration Date: 10/07/2024
• Device Model Number: 0157
• Device Catalogue Number: 0157
• Device Lot Number: 303727
• 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: 08/20/2024
• Supplement Date Received by Manufacturer: 09/18/2024; 04/15/2026
• Initial Report FDA Received Date: 09/18/2024
• Supplement Report FDA Received Date: 10/17/2024; 04/16/2026
• Date Device Manufactured: 10/07/2022
• 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
• Outcome Attributed to Adverse Event: Required Intervention; Hospitalization
• Patient Age: 79 YR
• Patient Sex: Female