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U.S. Department of Health and Human Services

MAUDE Adverse Event Report: GUIDANT CRM CLONMEL IRELAND INGENIO; IMPLANTABLE PULSE GENERATOR
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GUIDANT CRM CLONMEL IRELAND INGENIO; IMPLANTABLE PULSE GENERATOR Back to Search Results
Model Number K272
Medical Device Problem Code Failure to Capture (1081)
Health Effect - Clinical Code No Known Impact Or Consequence To Patient (2692)
Date of Event 06/14/2016
Type of Reportable Event Serious Injury
Additional Manufacturer Narrative
As no further information concerning this report is expected, our investigation is complete.This investigation will be updated should further information be provided.
 
Event or Problem Description
Boston scientific received information that this pacemaker and right ventricular (rv) lead exhibited loss of capture.An invasive procedure was performed.This lead was explanted and replaced.The device remains in service.No additional adverse patient effects were reported.
 
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Brand Name
INGENIO
Common Device Name
IMPLANTABLE PULSE GENERATOR
Manufacturer (Section D)
GUIDANT CRM CLONMEL IRELAND
guidant ireland
clonmel, tipperary ireland
MDR Report Key5795685
Report Number2124215-2016-10882
Device Sequence Number26217
Product Code LWP
UDI-Device Identifier00802526516955
UDI-Public(01)00802526516955(17)20170227
Combination Product (Y/N)N
Initial Reporter StatePR
Initial Reporter CountryUS
PMA/510(K) Number
N970003/S143
Number of Events Summarized1
Summary Report (Y/N)N
Device Implanted Year2015
Reporter Type Manufacturer
Report Source company representative
Initial Reporter Occupation Physician
Type of Report Initial
Report Date (Section B) 06/14/2016
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 Date02/27/2017
Device Model NumberK272
Other Device ID NumberVITALIO
Was Device Available for Evaluation? No
Was the Report Sent to FDA? Yes
Type of Report(Section G)Thirty-Day
Initial Date Received by Manufacturer 06/14/2016
Initial Report FDA Received Date07/14/2016
Is This a Single-Use Device that was
Reprocessed and Reused on a Patient? (Y/N)		 No
Patient Sequence Number1
Concomitant Medical Products
and Therapy/Usage Dates
7742
Outcome Attributed to Adverse Event Hospitalization; Life Threatening; Required Intervention;
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