MAUDE Adverse Event Report: BOSTON SCIENTIFIC CORPORATION VITALIO; PACEMAKER

Model Number	K277
Medical Device Problem Code	Incorrect, Inadequate or Imprecise Result or Readings (1535)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	11/23/2025
Type of Reportable Event	Serious Injury
Event or Problem Description
It was reported that this pacemaker had reverted to safety mode.Technical services (ts) was consulted, discussed safety mode parameters, and recommended device replacement.This pacemaker remains in service.No adverse patient effects were reported.
Additional Manufacturer Narrative
This report is being submitted to correct the information in section a.Patient information and section d.Suspect medical device.This report will be updated when additional investigation is complete.
Event or Problem Description
It was reported that this pacemaker had reverted to safety mode.Technical services (ts) was consulted, discussed safety mode parameters, and recommended device replacement.This pacemaker remains in service.No adverse patient effects were reported.Additional information received detailed this device was explanted and successfully replaced.No additional adverse patient effects were reported.

• Brand Name: VITALIO
• Common Device Name: PACEMAKER
• Manufacturer (Section D): BOSTON SCIENTIFIC CORPORATION; 4100 hamline avenue north; saint paul MN 55112
• Manufacturer (Section G): BOSTON SCIENTIFIC CORPORATION; cashel road; clonmel ; EI
• Manufacturer Contact: timothy degroot ; 4100 hamline avenue north; saint paul, MN 55112 ; 6515826168
• MDR Report Key: 23694168
• Report Number: 2124215-2025-88336
• Device Sequence Number: 16000520
• Product Code: LWP
• UDI-Device Identifier: 00802526516955
• UDI-Public: (01)00802526516955
• Combination Product (Y/N): N
• Initial Reporter State: AZ
• Initial Reporter Country: US
• PMA/510(K) Number: P150012/S000
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2014
• Device Explanted Year: 2025
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Health Professional
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 03/04/2026

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: 01/14/2015
• Device Model Number: K277
• Device Catalogue Number: K277
• Device Lot Number: 100216
• 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: 11/24/2025
• Supplement Date Received by Manufacturer: 03/03/2026
• Initial Report FDA Received Date: 12/02/2025
• Supplement Report FDA Received Date: 03/04/2026
• Date Device Manufactured: 04/04/2013
• 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: 62 YR
• Patient Sex: Male