MAUDE Adverse Event Report: ST. JUDE MEDICAL, INC. LIVEWIRE¿ DIAGNOSTIC CATHETER MEDIGUIDE ENABLED¿, MEDIUM SWEEP ELECTRODE SPACING; CATHETER, ELECTRODE RECORDING, OR PROBE, ELECTRODE RECORDING

Model Number	D402058
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Cardiac Perforation (2513)
Date of Event	04/03/2019
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
The results of the investigation are inconclusive since the device was not returned for analysis.The device history record was reviewed to ensure that each manufacturing and inspection operation was performed.Based on the information received, the cause of the reported pericardial effusion could not be conclusively determined.Per the ifu, cardiac perforation is an inherent risk of any electrode placement.
Event or Problem Description
Related manufacturing ref: 3005334138-2019-00195, 3008452825-2019-00160.During a redo pulmonary vein isolation procedure, the left atrium was successfully ablated near the pulmonary veins and the catheters were withdrawn toward the right atrium.After withdrawing the catheters to the right atrium, the patient became hypotensive.An intracardiac echogram revealed a pericardial effusion.A pericardiocentesis was performed and a drain was inserted until the patient stabilized.There were no performance issues with any abbott device.

• Brand Name: LIVEWIRE¿ DIAGNOSTIC CATHETER MEDIGUIDE ENABLED¿, MEDIUM SWEEP ELECTRODE SPACING
• Common Device Name: CATHETER, ELECTRODE RECORDING, OR PROBE, ELECTRODE RECORDING
• Manufacturer (Section D): ST. JUDE MEDICAL, INC.; 14901 deveau place; minnetonka MN 55345
• MDR Report Key: 8499205
• Report Number: 2182269-2019-00038
• Device Sequence Number: 14121242
• Product Code: DRF
• UDI-Device Identifier: 05414734216890
• UDI-Public: 05414734216890
• Combination Product (Y/N): N
• Initial Reporter State: AZ
• Initial Reporter Country: US
• PMA/510(K) Number: K101955
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 04/10/2019

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: Health Professional
• Device Expiration Date: 06/30/2020
• Device Model Number: D402058
• Device Lot Number: 6562258
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 04/03/2019
• Initial Report FDA Received Date: 04/10/2019
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: ADVISOR¿ HD GRID MAPPING CATHETER, SENSOR ENABLED¿; FLEXABILITY¿ ABLATION CATHETER, SENSOR ENABLED¿
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 62 YR
• Patient Weight: 88