MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a * report with the FDA on 2012-01-13 for UNKNOWN 4312 manufactured by Historical Cpi St. Paul.
[2563483]
Boston scientific received information that the ring lead was plugged into the bifurcated portion of the pacemaker and that this lead had a complete fracture of the conductor. This lead had a previous break near the terminal, but had been repaired and had a non-boston adaptor in place to put it into the device. The adaptor was cut off and the lead was surgically abandoned. However, upon the removal of the pacemaker, the header separated from the can without effort when a slight torque was applied.
Patient Sequence No: 1, Text Type: D, B5
[9534192]
As no further information concerning this report is expected, our investigation is complete. This investigation will be updated should further information be provided.
Patient Sequence No: 1, Text Type: N, H10
| Report Number | 2124215-2012-00567 |
| MDR Report Key | 2415545 |
| Report Source | * |
| Date Received | 2012-01-13 |
| Date of Report | 2011-12-14 |
| Date of Event | 2011-12-14 |
| Date Mfgr Received | 2011-12-14 |
| Date Added to Maude | 2012-01-13 |
| Event Key | 0 |
| Report Source Code | Manufacturer report |
| Manufacturer Link | Y |
| Number of Patients in Event | 0 |
| Adverse Event Flag | 3 |
| Product Problem Flag | 3 |
| Reprocessed and Reused Flag | 3 |
| Reporter Occupation | MEDICAL EQUIPMENT COMPANY TECHNICIAN/REPRESENTATIVE |
| Health Professional | 3 |
| Initial Report to FDA | 3 |
| Report to FDA | 3 |
| Event Location | 0 |
| Manufacturer Contact | SHARON ZURN |
| Manufacturer Street | 4100 HAMLINE AVE. N |
| Manufacturer City | ST. PAUL MN 55112 |
| Manufacturer Postal | 55112 |
| Manufacturer Phone | 6515824786 |
| Manufacturer G1 | HISTORICAL CPI ST. PAUL |
| Manufacturer Street | GUIDANT CORPORATION |
| Manufacturer City | SAINT PAUL MN |
| Single Use | 3 |
| Previous Use Code | 3 |
| Event Type | 3 |
| Type of Report | 3 |
| Brand Name | UNKNOWN |
| Generic Name | IMPLANTABLE LEAD |
| Product Code | NHW |
| Date Received | 2012-01-13 |
| Model Number | 4312 |
| ID Number | --- |
| Device Expiration Date | 1992-02-22 |
| Operator | LAY USER/PATIENT |
| Device Availability | N |
| Device Eval'ed by Mfgr | R |
| Device Sequence No | 1 |
| Device Event Key | 0 |
| Manufacturer | HISTORICAL CPI ST. PAUL |
| Manufacturer Address | GUIDANT CORPORATION SAINT PAUL MN |
| Patient Number | Treatment | Outcome | Date |
|---|---|---|---|
| 1 | 8158 | 1. Hospitalization; 2. Life Threatening; 3. Required No Informationntervention | 2012-01-13 |