MAUDE Adverse Event Report: MEDTRONIC IRELAND RESOLUTE INTEGRITY OTW; STENT, CORONARY, DRUG-ELUTING

Model Number	RSINT30015W
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Codes	Unspecified Infection (1930); Reaction (2414)
Date of Event	03/21/2018
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
If information is provided in the future, a supplemental report will be issued.
Event or Problem Description
It is reported that a patient had two resolute integrity drug-eluting stents implanted.It is reported that the patient was having breakouts and a rash that was getting worse, since having the devices implanted.It is stated that the patient had tested positive for allergies to nickel and chromium.
Additional Manufacturer Narrative
Additional information: two resolute integrity drug-eluting stents implanted (2018).The official diagnosis was that there was an allergic reaction.The patient's dermatologist indicated there was a sensitivity to nickel and chromium while the patient's cardiologist indicated that it was an autoimmune reaction.The patient is currently managing their symptoms and is receiving treatment for the breakouts and rash with medication and topical cream.The patient's symptoms have decreased after follow-up with physician.It was stated that other infections occurred in (b)(6) 2018 with these becoming worse in (b)(6) 2018.The patient had a further 4 stents implanted around 20 years ago and also had 2 stents in 2017.If information is provided in the future, a supplemental report will be issued.
Additional Manufacturer Narrative
Medtronic is submitting this report to comply with fda reporting regulations under 21 cfr parts 4 and 803.This report is based upon information obtained by medtronic, which the company may not have been able to fully investigate or verify prior to the date the report was required by the fda.Medtronic has made reasonable efforts to obtain more complete information and has provided as much relevant information as is available to the company as of the submission date of this report.This report does not constitute an admission or a conclusion by fda, medtronic, or its employees that the device, medtronic, or its employee caused or contributed to the event described in the report.In particular, this report does not constitute an admission by anyone that the product described in this report has any ¿defects¿ or has ¿malfunctioned¿.These words are included in the fda 3500a form and are fixed items for selection created by the fda to categorize the type of event solely for the purpose of regulatory reporting.Medtronic objects to the use of these words and others like them because of the lack of definition and the connotations implied by these terms.This statement should be included with any information or report disclosed to the public under the freedom of information act.Any required fields that are unpopulated are blank because the information is currently unknown or unavailable.A good faith effort will be made to obtain the applicable information relevant to the report.If information is provided in the future, a supplemental report will be issued.

• Brand Name: RESOLUTE INTEGRITY OTW
• Common Device Name: STENT, CORONARY, DRUG-ELUTING
• Manufacturer (Section D): MEDTRONIC IRELAND; parkmore business park west; galway
• MDR Report Key: 9726657
• Report Number: 9612164-2020-00790
• Device Sequence Number: 19565141
• Product Code: NIQ
• UDI-Device Identifier: 00613994793416
• UDI-Public: 00613994793416
• Combination Product (Y/N): N
• PMA/510(K) Number: P110013
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2018
• Reporter Type: Manufacturer
• Report Source: company representative,consum
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 05/06/2020

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: 06/16/2019
• Device Model Number: RSINT30015W
• Device Catalogue Number: RSINT30015W
• Device Lot Number: 0008682413
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 02/12/2020
• Supplement Date Received by Manufacturer: 03/09/2020; 05/05/2020
• Initial Report FDA Received Date: 02/19/2020
• Supplement Report FDA Received Date: 03/25/2020; 05/06/2020
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Other
• Patient Age: 70 YR
• Patient Weight: 68