MAUDE Adverse Event Report: ST. JUDE MEDICAL, INC.(CRM-SYLMAR) ASSURITY PLUS; PULSE GENERATOR, PERMANENT, IMPLANTABLE

Model Number	PM1260
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Unspecified Infection (1930)
Date of Event	01/15/2025
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
The sterilization records were reviewed and no evidence of abnormal sterilization cycle was found.The results of the investigation are inconclusive since the device was not returned for analysis.Based on the information received, the cause of the reported incident could not be conclusively determined.
Event or Problem Description
It was reported that the patient presented to hospital with mssa bacteremia infection.The pacemaker, right atrial lead and right ventricular lead were explanted.The patient was in stable condition throughout the procedure.
Additional Manufacturer Narrative
Correction b5 statement.Only the pm and rv lead were explanted.
Event or Problem Description
It was reported that the patient presented to hospital with mssa bacteremia infection.The pacemaker and right ventricular lead were explanted.The patient was in stable condition throughout the procedure.
Additional Manufacturer Narrative
Endocarditis was added in section b5.
Event or Problem Description
It was reported that the patient presented to hospital with mssa bacteremia infection and endocarditis at device pocket.The pacemaker and right ventricular lead were explanted.The patient was in stable condition throughout the procedure.

• Brand Name: ASSURITY PLUS
• Common Device Name: PULSE GENERATOR, PERMANENT, IMPLANTABLE
• Manufacturer (Section D): ST. JUDE MEDICAL, INC.(CRM-SYLMAR); 15900 valley view court; sylmar CA 91342
• Manufacturer (Section G): ST. JUDE MEDICAL, INC.(CRM-SYLMAR); 15900 valley view court; sylmar CA 91342
• Manufacturer Contact: richard williamson ; 15900 valley view court; sylmar, CA 91342
• MDR Report Key: 21194656
• Report Number: 2017865-2025-11221
• Device Sequence Number: 8534443
• Product Code: NVZ
• UDI-Device Identifier: 05414734507080
• UDI-Public: (01)05414734507080(10)S000028417(17)180630
• Combination Product (Y/N): N
• Initial Reporter Country: CA
• PMA/510(K) Number: P880086
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2017
• Device Explanted Year: 2025
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Foreign,Health Professional,User Facility,Company Representative
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 03/04/2025

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: 06/30/2018
• Device Model Number: PM1260
• Device Lot Number: S000028417
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 01/15/2025
• Supplement Date Received by Manufacturer: 01/28/2025; 02/14/2025
• Initial Report FDA Received Date: 01/21/2025
• Supplement Report FDA Received Date: 01/27/2025; 03/03/2025
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 01/05/2017
• 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
• Patient Sex: Unknown