MAUDE Adverse Event Report: ST. JUDE MEDICAL, INC. CPS AIM SL SUBSELECTOR, SUB-ACU VALVE; CATHETER

Model Number DS2N021-59

Device Problem Device Operational Issue (2914)

Patient Problem No Known Impact Or Consequence To Patient (2692)

Event Date 10/16/2017

Event Type  malfunction  

Manufacturer Narrative

The results of the investigation are inconclusive since the device was not returned for analysis.Based on the information received, the cause of the reported incident could not be conclusively determined.

Event Description

During the implant procedure, it was difficult to cut the introducer with the corresponding slitter.The difficulty in cutting the introducer resulted in the left ventricular lead becoming dislodged by the physician.The lead was explanted and replaced and the subselector was replaced to resolve the event.The dislodgement and replacement of the lv lead caused a thirty minute increase in the duration of the procedure.The patient was stable following the procedure.

• Brand Name: CPS AIM SL SUBSELECTOR, SUB-ACU VALVE
• Type of Device: CATHETER
• Manufacturer (Section D): ST. JUDE MEDICAL, INC.; 15900 valley view court; sylmar CA 91342
• Manufacturer (Section G): ST. JUDE MEDICAL, INC.; 15900 valley view court; sylmar CA 91342
• Manufacturer Contact: robert greenleaf ; 15900 valley view court; sylmar, CA 91342 ; 8184932577
• MDR Report Key: 7021166
• MDR Text Key: 92211669
• Report Number: 2017865-2017-34427
• Device Sequence Number: 1
• Product Code: DQY
• Combination Product (y/n): N
• Reporter Country Code: UK
• PMA/PMN Number: K090613
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: company representative,foreig
• Reporter Occupation: Physician
• Type of Report: Initial
• Report Date: 11/10/2017

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
• Device Operator: Health Professional
• Device Expiration Date: 02/28/2019
• Device Model Number: DS2N021-59
• Device Lot Number: 5430986
• Other Device ID Number: 05414734218023
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Initial Date Manufacturer Received: 10/16/2017
• Initial Date FDA Received: 11/10/2017
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• Date Device Manufactured: 03/18/2016
• Is the Device Single Use?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Initial
• Patient Sequence Number: 1