MAUDE Adverse Event Report: MEDTRONIC PUERTO RICO VILLALBA CAPSUREFIX LEAD; PERMANENT PACEMAKER ELECTRODE

Model Number	5568-53
Medical Device Problem Codes	Failure to Capture (1081); Device Sensing Problem (2917); High Capture Threshold (3266)
Health Effect - Clinical Code	Appropriate Clinical Signs, Symptoms and Conditions Term/Code Not Available (4581)
Date of Event	05/28/2025
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Continuation of d10: dtpa2d1 crt-d implanted (b)(6) 2023.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.
Event or Problem Description
It was reported that there was a possible sensing issue on the right atrial (ra) lead and capture issue as capture could not be confirmed. it was also reported there was possible sensing issue on the right ventricular (rv) lead.It appeared the ra lead pace was sensed on the ventricular channel possibly causing pacing inhibition.It was noted the patient felt a ¿twinge¿ in their chest.The leads remain in use.No further patient complications have been reported as a result of this event.
Event or Problem Description
It was reported that the there was a possible sensing issue on the right atrial (ra) lead and capture issue as capture could not be confirmed.It was also noted there was high threshold on the ra lead.It was also reported there was possible sensing issue on the right ventricular (rv) lead.It appeared the ra lead pace was sensed on the ventricular channel possibly causing pacing inhibition.It was noted the patient felt a ¿twinge¿ in their chest.The leads remain in use.No further patient complications have been reported as a result of this event.
Additional Manufacturer Narrative
Correction: b5, h6.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: CAPSUREFIX LEAD
• Common Device Name: PERMANENT PACEMAKER ELECTRODE
• Manufacturer (Section D): MEDTRONIC PUERTO RICO VILLALBA; road 149 km 56.3; villalba PR 00766
• Manufacturer (Section G): MEDTRONIC PUERTO RICO VILLALBA; road 149 km 56.3; villalba PR 00766
• Manufacturer Contact: gerard torenvliet ; 8200 coral sea st ne; mounds view, MN 55112-4391 ; 7635269277
• MDR Report Key: 22299157
• Report Number: 2649622-2025-16757
• Device Sequence Number: 8628609
• Product Code: DTB
• UDI-Device Identifier: 00885074248592
• UDI-Public: (01)00885074248592(17)101118(21)LDN125669V
• Combination Product (Y/N): N
• Initial Reporter State: MA
• Initial Reporter Country: US
• PMA/510(K) Number: P930039
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2009
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Health Professional
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 07/21/2025

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Operator of Device: Lay User/Patient
• Device Expiration Date: 11/18/2010
• Device Model Number: 5568-53
• Device Catalogue Number: 5568-53
• 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: 05/29/2025
• Supplement Date Received by Manufacturer: 07/18/2025
• Initial Report FDA Received Date: 06/20/2025
• Supplement Report FDA Received Date: 07/21/2025
• Date Device Manufactured: 11/26/2008
• 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: 694758 LEAD, 419478
• Patient Age: 76 YR
• Patient Sex: Male
• Patient Weight: 88 KG