Brand Name | INGEVITY |
Type of Device | IMPLANTABLE LEAD |
Manufacturer (Section D) |
CPI - DEL CARIBE |
guidant puerto rico b. v. |
dorado PR |
|
Manufacturer (Section G) |
CPI - DEL CARIBE |
guidant puerto rico b. v. |
|
dorado PR |
|
Manufacturer Contact |
tim
degroot
|
4100 hamline ave. n |
st. paul, MN
|
6515826168
|
|
MDR Report Key | 7981589 |
MDR Text Key | 124279052 |
Report Number | 2124215-2018-16406 |
Device Sequence Number | 1 |
Product Code |
LWP
|
UDI-Device Identifier | 00802526523458 |
UDI-Public | (01)00802526523458(17)20190829 |
Combination Product (y/n) | N |
Reporter Country Code | US |
Number of Events Reported | 1 |
Summary Report (Y/N) | N |
Report Source |
Manufacturer
|
Source Type |
health professional |
Reporter Occupation |
Physician
|
Type of Report
| Initial |
Report Date |
08/08/2018 |
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
|
Device Operator |
Lay User/Patient
|
Device Expiration Date | 08/29/2019 |
Device Model Number | 7741 |
Was Device Available for Evaluation? |
No
|
Is the Reporter a Health Professional? |
Yes
|
Was the Report Sent to FDA? |
Yes
|
Initial Date Manufacturer Received |
08/08/2018 |
Initial Date FDA Received | 10/18/2018 |
Was Device Evaluated by Manufacturer? |
Device Not Returned to Manufacturer
|
Date Device Manufactured | 08/29/2017 |
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 |
Patient Outcome(s) |
Hospitalization;
Life Threatening;
Required Intervention;
|
Patient Age | 79 YR |