Brand Name | ANTHEM RF CRT-P |
Type of Device | IMPLANTABLE PACEMAKER PULSE GENERATOR |
Manufacturer (Section D) |
ST. JUDE MEDICAL, INC.(CRM-SYLMAR) |
15900 valley view court |
sylmar CA 91342 |
|
Manufacturer (Section G) |
ST. JUDE MEDICAL, INC.(CRM-SYLMAR) |
15900 valley view court |
|
sylmar CA 91342 |
|
Manufacturer Contact |
elizabeth
boltz
|
15900 valley view court |
sylmar, CA 91342
|
|
MDR Report Key | 9434673 |
MDR Text Key | 169792629 |
Report Number | 2017865-2019-17561 |
Device Sequence Number | 1 |
Product Code |
NKE
|
UDI-Device Identifier | 05414734503785 |
UDI-Public | 05414734503785 |
Combination Product (y/n) | N |
Reporter Country Code | US |
PMA/PMN Number | P030035 |
Number of Events Reported | 1 |
Summary Report (Y/N) | N |
Report Source |
Manufacturer
|
Source Type |
company representative,user f |
Reporter Occupation |
Non-Healthcare Professional
|
Type of Report
| Initial |
Report Date |
12/06/2019 |
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
|
Device Operator |
Health Professional
|
Device Expiration Date | 05/31/2014 |
Device Model Number | PM3210 |
Device Lot Number | 3871139 |
Was the Report Sent to FDA? |
No
|
Initial Date Manufacturer Received |
11/22/2019 |
Initial Date FDA Received | 12/07/2019 |
Was Device Evaluated by Manufacturer? |
Device Not Returned to Manufacturer
|
Date Device Manufactured | 11/26/2012 |
Is the Device Single Use? |
Yes
|
Is This a Reprocessed and Reused Single-Use Device? |
Yes
|
Type of Device Usage |
Initial
|
Patient Sequence Number | 1 |
Patient Outcome(s) |
Required Intervention;
|
Patient Age | 83 YR |