MAUDE Adverse Event Report: Medtronic Puerto Rico Villalba SelectSecure MRI SureScan; DRUG ELUTING PERMANENT RIGHT VENTRICULAR (RV)

Model Number	383059
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Appropriate Clinical Signs, Symptoms and Conditions Term/Code Not Available (4581)
Date of Event	06/29/2026
Type of Reportable Event	Death
Event or Problem Description
It was reported that the patient expired approximately two months post-implant.The cause of death was provided as starvation ketosis in the setting of esophageal dysmotility with extensive tertiary/contractions.The disposition of the cardiac resynchronization therapy defibrillator (crt-d) system remains unknown.
Additional Manufacturer Narrative
Continuation of d10: product id dtpa2qq crt-d implanted: (b)(6) 2026 explanted: (b)(6) 2026 product id 479888 lead implanted: (b)(6) 2026 explanted: (b)(6) 2026 product id 3930m74 lead implanted: (b)(6) 2026 explanted: (b)(6) 2026 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: SelectSecure MRI SureScan
• Common Device Name: DRUG ELUTING PERMANENT RIGHT VENTRICULAR (RV)
• 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--439 ; +1(763)526-9277
• MDR Report Key: 50676233
• Report Number: 2649622-2026-26676
• Device Sequence Number: 13369433
• Product Code: NVN
• UDI-Device Identifier: 00763000740252
• UDI-Public: (01)00763000740252(17)280307(20)01
• Combination Product (Y/N): N
• Initial Reporter State: AZ
• Initial Reporter Country: US
• PMA/510(K) Number: P030036
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2026
• Device Explanted Year: 2026
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Health Professional
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 09/08/2026

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?: No
• Operator of Device: Lay User/Patient
• Device Model Number: 383059
• Device Catalogue Number: 383059
• 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: 08/11/2026
• Initial Report FDA Received Date: 09/08/2026
• Date Device Manufactured: 03/16/2026
• 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: "See H11...."
• Outcome Attributed to Adverse Event: Death
• Patient Age: 88 YR
• Patient Sex: Male