| Model Number |
DB-1232 |
| Medical Device Problem Codes |
Unexpected Therapeutic Results (1631); Wireless Communication Problem (3283)
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| Health Effect - Clinical Code |
Shaking/Tremors (2515)
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| Date of Event |
11/29/2025
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Type of Reportable Event
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Serious Injury
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Event or Problem Description
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It was reported that the deep brain stimulation (dbs) patient experienced a communication error with the implantable pulse generator (ipg) and a loss of stimulation resulting in a return of their pre-existing tremor after they underwent a cardioversion.The cardioversion was performed at 200 voltages at the right shoulder above the ipg which was turned off prior to the procedure.As such, the physician assessed the cardioversion may have contributed to the communication difficulty and loss of stimulation.Therefore, the patient underwent a revision procedure during which the ipg was explanted and replaced.The patient was doing well postoperatively.
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Additional Manufacturer Narrative
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Device analysis performed on the returned ipg revealed that it would not communicate with a known working remote control (rc) or clinician programmer (cp) and was unable to be charged despite multiple charging attempts.Functional testing was unable to be performed and the data logs were unable to be retrieved.The ipg was then cut open and internal electrical measurements revealed a high sleep current and lower than expected resistance, indicating a damaged application specific integrated circuit (asic) chip.This damaged asic is typical of exposure to high voltage transients and high current sources such as electrocautery.A labeling review confirmed that electrocautery or some other medical therapies or procedures may turn stimulation off or may cause permanent damage to the device if used in close proximity, as documented in the ifu.Therefore this type of damage was likely caused by an external high voltage or high current transient source such as the reported cardioversion and was an unintended use error that had likely caused or contributed to the event.
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Event or Problem Description
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It was reported that the deep brain stimulation (dbs) patient experienced a communication error with the implantable pulse generator (ipg) and a loss of stimulation resulting in a return of their pre-existing tremor after they underwent a cardioversion.The cardioversion was performed at 200 voltage at the right shoulder above the ipg which was turned off prior to the procedure.As such, the physician assessed the cardioversion may have contributed to the communication difficulty and loss of stimulation.Therefore, the patient underwent a revision procedure during which the ipg was explanted and replaced.The patient was doing well postoperatively.
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Search Alerts/Recalls
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