MAUDE Adverse Event Report: MPRI CAPSURE SP NOVUS; ELECTRODE, PACEMAKER, PERMANENT

Model Number	5592-45
Medical Device Problem Code	Under-Sensing (1661)
Health Effect - Clinical Code	Atrial Tachycardia (1731)
Date of Event	12/05/2017
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
If information is provided in the future, a supplemental report will be issued.
Event or Problem Description
It was reported that the patient experienced atrial tachycardia.Upon device interrogation, it was revealed that there was atrial un der-sensing and mode switching on the right atrial (ra) lead.It was also noted that there was one under-sensed r-wave on the right ventricular (rv) lead.The ra and rv lead remain in use.No further patient complications have been reported as a result of this event.

• Brand Name: CAPSURE SP NOVUS
• Common Device Name: ELECTRODE, PACEMAKER, PERMANENT
• Manufacturer (Section D): MPRI; road 149 km 56.3; villalba PR 00766
• MDR Report Key: 7254284
• Report Number: 2649622-2018-00592
• Device Sequence Number: 13487824
• Product Code: DTB
• UDI-Device Identifier: 00643169590724
• UDI-Public: 00643169590724
• Combination Product (Y/N): N
• Initial Reporter State: MI
• Initial Reporter Country: US
• PMA/510(K) Number: P850089
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2017
• Reporter Type: Manufacturer
• Report Source: health professional
• Initial Reporter Occupation: Health Professional
• Type of Report: Initial
• Report Date (Section B): 02/08/2018

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
• Operator of Device: Lay User/Patient
• Device Expiration Date: 01/21/2018
• Device Model Number: 5592-45
• Device Catalogue Number: 5592-45
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 12/05/2017
• Initial Report FDA Received Date: 02/08/2018
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Age: 80 YR