MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a company representative,foreig report with the FDA on 2020-03-31 for QUARTET LEAD DOUBLE BEND, 86 CM 1457Q/86 manufactured by St. Jude Medical, Inc.(crm-sylmar).
[185728682]
This product is registered as a combination product. The results of the investigation are inconclusive since the device was not returned for analysis. Based on the information received, the cause of the reported incident could not be conclusively determined.
Patient Sequence No: 1, Text Type: N, H10
[185728683]
Related manufacturer reference number: 2017865-2020-04445, related manufacturer reference number: 2017865-2020-04451, related manufacturer reference number: 2017865-2020-04453. It was reported that the patient deceased. There is no known allegation from a health professional that suggests the death was related to the device. It was reported that the cause of death was cardiac and pulmonary arrest.
Patient Sequence No: 1, Text Type: D, B5
| Report Number | 2017865-2020-04449 |
| MDR Report Key | 9903857 |
| Report Source | COMPANY REPRESENTATIVE,FOREIG |
| Date Received | 2020-03-31 |
| Date of Report | 2020-03-31 |
| Date of Event | 2019-11-11 |
| Date Mfgr Received | 2020-03-16 |
| Device Manufacturer Date | 2017-11-03 |
| Date Added to Maude | 2020-03-31 |
| 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 | OTHER HEALTH CARE PROFESSIONAL |
| Health Professional | 3 |
| Initial Report to FDA | 3 |
| Report to FDA | 3 |
| Event Location | 3 |
| Manufacturer Contact | ELIZABETH BOLTZ |
| Manufacturer Street | 15900 VALLEY VIEW COURT |
| Manufacturer City | SYLMAR CA 91342 |
| Manufacturer Country | US |
| Manufacturer Postal | 91342 |
| Manufacturer G1 | ST. JUDE MEDICAL, INC.(CRM-SYLMAR) |
| Manufacturer Street | 15900 VALLEY VIEW COURT |
| Manufacturer City | SYLMAR CA 91342 |
| Manufacturer Country | US |
| Manufacturer Postal Code | 91342 |
| Single Use | 3 |
| Previous Use Code | 3 |
| Event Type | 3 |
| Type of Report | 3 |
| Brand Name | QUARTET LEAD DOUBLE BEND, 86 CM |
| Generic Name | PERMANENT PACEMAKER ELECTRODE |
| Product Code | OJX |
| Date Received | 2020-03-31 |
| Model Number | 1457Q/86 |
| Catalog Number | 1457Q/86 |
| Lot Number | A000046960 |
| Operator | HEALTH PROFESSIONAL |
| Device Availability | N |
| Device Eval'ed by Mfgr | R |
| Device Sequence No | 1 |
| Device Event Key | 0 |
| Manufacturer | ST. JUDE MEDICAL, INC.(CRM-SYLMAR) |
| Manufacturer Address | 15900 VALLEY VIEW COURT SYLMAR CA 91342 US 91342 |
| Patient Number | Treatment | Outcome | Date |
|---|---|---|---|
| 1 | 2088 | 1. Death | 2020-03-31 |