Brand Name | ENDOTAK RELIANCE |
Type of Device | IMPLANTABLE LEAD |
Baseline Brand Name | ENDOTAK RELIANCE |
Baseline Generic Name | IMPLANTABLE LEAD |
Baseline Catalogue Number | NA |
Baseline Model Number | 0158 |
Baseline Device 510(K) Number | |
Baseline Device PMA Number | |
Manufacturer (Section F) |
CARDIAC PACEMAKERS, INC |
guidant puerto rico b.v. |
#12, rd. #698 |
dorado PR 00646 UNK |
|
Manufacturer (Section D) |
CARDIAC PACEMAKERS, INC |
guidant puerto rico b.v. |
#12, rd. #698 |
dorado PR 00646 UNK |
|
Manufacturer (Section G) |
CARDIAC PACEMAKERS, INC. |
4100 hamline ave., north |
|
st. paul MN 55112 5798 |
|
Device Event Key | 533531 |
MDR Report Key | 544123 |
Event Key | 516795 |
Report Number | 2124215-2004-08283 |
Device Sequence Number | 1 |
Product Code | LWS |
Report Source |
Manufacturer
|
Source Type |
Health Professional
|
Reporter Occupation |
Physician
|
Remedial Action |
Other
|
Type of Report
| Initial |
Report Date |
06/17/2004 |
1 Device Was Involved in the Event | |
1 Patient Was Involved in the Event | |
Date FDA Received | 08/10/2004 |
Is This An Adverse Event Report? |
Yes
|
Is This A Product Problem Report? |
No
|
Device Operator |
UNKNOWN
|
Device MODEL Number | 0158 |
Was Device Available For Evaluation? |
No
|
Is The Reporter A Health Professional? |
Yes
|
Was the Report Sent to FDA? |
|
Event Location |
Hospital
|
Date Report TO Manufacturer | 06/17/2004 |
Date Manufacturer Received | 06/17/2004 |
Was Device Evaluated By Manufacturer? |
Device Not Returned To Manufacturer
|
Is The Device Single Use? |
Yes
|
Is the Device an Implant? |
Yes
|
Is this an Explanted Device? |
|
Type of Device Usage |
Unkown
|
Patient TREATMENT DATA |
Date Received: 08/10/2004 Patient Sequence Number: 1 |
# | Treatment | Treatment Date |
1 |
THE DEVICE 4469/417313 WAS IMPLANTED 17-JUN-2004 |
06/17/2004 |
2 |
THE DEVICE A155/107527 WAS IMPLANTED 17-JUN-2004 |
06/17/2004 |
|
|
|