MAUDE MDR 9770291

MDR report key
9770291
Report number
3002808157-2020-09293
Event key
0
Event type
3
Date of event
2019-11-12
Date received
2020-02-28
Adverse event
3
Product problem
3
Patients in event
0
Reporter occupation
0
Health professional
3
Initial report to FDA
3
Event location
3

Manufacturer Contact#

Contact
MEREDITH ADAMS
Address
40 LIBERTY BLVD. 65-1A MALVERN, PA US
Phone
448-448-4486
Report source
M
Manufacturer link flag
Y

Devices#

Seq, Brand, Generic table
SeqBrandGenericManufacturerProduct codeModelCatalogLotPMA510(k)ImplantEvaluatedAvailability
1MAGNETOM SKYRASYSTEM, NUCLEAR MAGNETIC RESONANCE IMAGINGSIEMENS HEALTHCARE GMBH- MRLNH10432915Y Y

Patients#

Sequence, Received, Treatment table
SequenceReceivedTreatmentOutcome
12020-02-2801. O; 2. R

Event Narratives#

N

Patient 1

SIEMENS HAS COMPLETED AN INVESTIGATION OF THE REPORTED EVENT. THE ROOT CAUSE WAS DETERMINED TO BE A USER ERROR. THE SYSTEM IS EQUIPPED WITH A SQUEEZE BALL AND AN INTERCOM FOR THE PATIENT TO ALERT THE OPERATOR IN THE EVENT OF EXPERIENCING DISCOMFORT. WITH THESE EXISTING SAFETY FEATURES, A DEATH OR SERIOUS INJURY IS UNLIKELY. THERE IS A CLEAR WARNING IN THE MAGNETOM FAMILY OPERATOR MANUAL - MR SYSTEM SYNGO MR E11. IN GENERAL, AN MR EXAMINATION IS CONTRAINDICATED FOR PATIENTS WITH ELECTRONIC OR ELECTRONICALLY CONDUCTIVE IMPLANTS OR METALS, ESPECIALLY THOSE CONTAINING FERROMAGNETIC FOREIGN MATTER. CERTAIN IMPLANTABLE MEDICAL DEVICES HAVE BEEN CLEARED, APPROVED AND/OR LICENSED BY THE COMPETENT GOVERNMENTAL AUTHORITIES AND/OR LABELED BY THE DEVICE MANUFACTURER AS "MR CONDITIONAL". IT IS THE RESPONSIBILITY OF THE DEVICE MANUFACTURER TO DECLARE AN IMPLANTABLE MEDICAL DEVICE AS MR CONDITIONAL IF APPROPRIATE AND TO DEFINE THE CONDITIONS (CONSTRAINTS) FOR SAFE MR SCANNING. THE MR OPERATOR MUST BE AWARE OF ANY SUCH CONDITIONS FOR MR SCANNING. IT IS THE OBLIGATION OF THE MR OPERATOR TO ASSURE THAT THESE CONDITIONS ARE STRICTLY ADHERED TO. TO OBTAIN THESE SPECIFIC CONDITIONS THE MR OPERATOR MAY REFER TO THE LABELING OF THE IMPLANTABLE MEDICAL DEVICE OR CONTACT THE DEVICE MANUFACTURER. SIEMENS MR DOES NOT ASSUME RESPONSIBILITY OR LIABILITY FOR THE OPERATION OF THE MR SYSTEM WITH ANY IMPLANTABLE MEDICAL DEVICE.

D

Patient 1

IT WAS REPORTED TO SIEMENS THAT AN ADVERSE EVENT OCCURRED WHILE OPERATING THE MAGNETOM SKYRA SYSTEM. AN IMPLANTED VNS (VAGUS NERVE STIMULATION) DEVICE HEATED UP DURING THE MRI SCAN AND CAUSED A BURNING/GLOWING EXPERIENCE FOR THE PATIENT IN THE LEFT THORACIC AREA. THE PATIENT PRESSED THE SQUEEZE BALL DURING OR AFTER THE THIRD MEASUREMENT. NO INJURIES WERE VISIBLE ON THE SKIN. AFTER ABORTING THE MRI SCAN, THE PATIENT WAS IMMEDIATELY TRANSFERRED TO THE EMERGENCY DEPARTMENT FOR EXAMINATION. THE PALPATION AROUND THE IMPLANT WAS PAINFUL AND THE PATIENT SUFFERED SWALLOWING PROBLEMS. THE PATIENTS LAB AND ECG WERE NORMAL. THE PATIENT WENT HOME LATER THAT DAY WITH PAIN MEDICATION. THE PATIENT IS NOW SCHEDULED FOR SURGICAL REMOVAL OF THE VNS IMPLANT AND LEAD.