HEARTSINE SAMARITAN PAD

K041067 · Heartsine Technologies, Inc. · MKJ · May 25, 2004 · Cardiovascular

Device Facts

• Record ID: K041067
• Device Name: HEARTSINE SAMARITAN PAD
• Applicant: Heartsine Technologies, Inc.
• Product Code: MKJ · Cardiovascular
• Decision Date: May 25, 2004
• Decision: SESE
• Submission Type: Special
• Regulation: 21 CFR 870.5310
• Device Class: Class 3
• Attributes: Therapeutic, Pediatric

Intended Use

The HeartSine Samaritan® PAD is indicated for use on victims of cardiac arrest who are exhibiting the following signs: Unconscious. Not breathing. Without circulation. The Samaritan® PAD is intended for use by personnel who have been trained in its operation. Users should have received training in basic life support / AED, advanced life support or a physician-authorized emergency medical response training program. The Samaritan® PAD is not currently indicated for use on children less than 8 years old.

Device Story

Portable, battery-operated AED for cardiac arrest treatment. Inputs: patient heart rhythm via two non-sterile, single-use, self-adhesive, conductive gelled electrodes. Operation: proprietary analysis algorithm determines shock/no-shock decision; if shock required, device charges to 100J, 150J, or 200J escalating energy levels; user presses illuminated button to deliver truncated exponential biphasic waveform. After three shocks, device pauses 60 seconds for CPR. Used in emergency settings by trained responders. Features LED graphic prompts, automated self-tests, and internal event data recording (1.5 hours ECG). Data downloadable via USB to HeartSine SAVER software for review/annotation. Includes training module that disables energy delivery for simulation. Benefits: provides rapid, automated defibrillation therapy to restore circulation.

Clinical Evidence

Bench testing and performance documentation submitted. Hardware and software tested per industry standards. Efficacy of the SCOPE biphasic waveform demonstrated in prior animal and human clinical trials.

Technological Characteristics

Portable AED; lithium manganese dioxide battery; truncated exponential biphasic waveform; 100J/150J/200J escalating energy. Connectivity: USB port for data download and configuration. User interface: LED graphic display and voice prompts. Integrated training module. Software: proprietary analysis algorithm.

Indications for Use

Indicated for cardiac arrest victims who are unconscious, not breathing, and pulseless. Intended for trained personnel (BLS/AED, ALS, or physician-authorized emergency responders). Contraindicated for children under 8 years old.

Regulatory Classification

Identification

An automated external defibrillator (AED) system consists of an AED and those accessories necessary for the AED to detect and interpret an electrocardiogram and deliver an electrical shock (e.g., battery, pad electrode, adapter, and hardware key for pediatric use). An AED system analyzes the patient's electrocardiogram, interprets the cardiac rhythm, and automatically delivers an electrical shock (fully automated AED), or advises the user to deliver the shock (semi-automated or shock advisory AED) to treat ventricular fibrillation or pulseless ventricular tachycardia.

Predicate Devices

• HeartSine Samaritan® AED (K023854)
• Phillips Medical Onsite M5066A (K020715)

Submission Summary (Full Text)

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MAY 2 5 2004

# 510(k) Summary

#### Date Summary Prepared:

April 21, 2004

#### Submitter's Name and Address:

HeartSine Technologies, Inc. 940 Calle Amanecer, Suite E San Clemente, CA 92673

#### Contact Person:

William J. Smirles, EMT-P Telephone: [phone] Facsimile: 1.517.809.6748

#### Device Name:

Proprietary Name: HeartSine Samaritan® PAD Common Name: Automated External Defibrillator Classification Names: DC-Defibrillator, Low Energy

#### Device Description:

The HeartSine Samaritan® PAD is a small, lightweight portable, battery operated automated external defibrillator (AED) designed to treat victims of a cardiac arrest. The Samaritan® PAD incorporates a simple user interface of voice prompts and visual graphic prompts to guide the user. A proprietary analysis algorithm automatically renders a shock or no-shock decision. The Samaritan® PAD analysis algorithm is identical to the Samaritan® AED model which is in commercial distribution and which has been premarket cleared under K023854. The Samaritan® PAD functions identical to the earlier model Samaritan® AED. If a shock is required, the Samaritan® PAD will automatically charge to the appropriate energy level and prompt the user to press an illuminated shock button - to deliver the therapeutic energy to the patient. A low energy, escalating truncated exponential biphasic waveform pulse is delivered. A 100 Joule, 150 Joule, 200 Joule escalating energy sequence is used. After three consecutive shocks have been administered, the Samaritan® PAD will pause 60 seconds to allow cardiopulmonary resuscitation to be performed. The Samaritan® PAD uses two non-sterile, single use, self-adhesive, conductive adhesive gelled defibrillation/monitoring electrodes to obtain the patient's heart rhythm and, if required, deliver the defibrillation pulse to the patient.

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The Samaritan® PAD incorporates the following features:

- An LED graphic display providing visual graphic prompting to the . user
- Automated self tests with an LED flashing status indicator .
- Integral event data recording �

The Samaritan® PAD uses a disposable, non-rechargeable lithium manganese dioxide battery to operate the Samaritan® PAD for a minimum of 3 hours of continuous operation or provide a minimum of 30 - 200 Joule shocks. The disposable battery is housed in a plastic tray with the disposable defibrillation pads. By housing the battery in the same rigid plastic tray as the electrodes, this will greatly assist the end user in keeping the device in a state of readiness. This will also help eliminate the chance that the end user would respond to an incident with a good battery but expired electrodes, as could happen with many other AEDs currently.

Event details are recorded internally in the Samaritan® PAD for later retrieval on a computer. 1.5 hours of continuous ECG as well as incident events time stamped are recorded. Event and incident data can be viewed, printed, annotated and forwarded using the HeartSine SAVER software program. The Samaritan® PAD incorporates a USB communication port that allows for downloading event details to the SAVER software program. This USB port also allows for changing language settings for the Samaritan® PAD voice prompts and allows for customizing the factory settings.

Samaritan® PAD also incorporates a training module which converts the Samaritan® PAD into a training device. The training module will automatically disable the Samaritan® PAD energy delivery capability. This training module will allow the user to select training scripts, which simulate different rescue and demonstration scenarios.

#### Indications for Use:

The HeartSine Samaritan® AED is indicated for use on victims of cardiac arrest who are exhibiting the following signs:

- . Unconscious
- Not breathing .
- Without circulation .

The Samaritan® AED is intended for use by personnel who have been trained in its operation. Users should have received training in basic life support / AED. advanced life support or a physician-authorized emergency medical response training program. The Samaritan® AED is not currently indicated for use on children less than 8 years old.

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#### Predicate Device:

HeartSine Technologies, Inc. Phillips Medical

Samaritan® AED Onsite M5066A

(K023854) (K020715)

#### Substantial Equivalence:

The HeartSine Samaritan® PAD is substantially equivalent to those of the previously cleared HeartSine Samaritan® AED (K023854) and the Phillips Onsite M5066A (K020715). The Samaritan® PAD does not raise any new issues of safety and effectiveness.

#### Summary of Performance Testing:

Testing and performance documentation has been submitted with the 510(k) submission. These data demonstrate that the Samaritan® PAD complies with the applicable FDA guidelines and industry standards. The Samaritan® PAD was developed under extensive design controls. The hardware and software were tested in accordance with established industry standards and found to perform as intended. The efficacy of the HeartSine SCOPE biphasic waveform in this device has been demonstrated in animal and human clinical trials.

The results of the testing have shown the Samaritan® PAD does not raise any new questions of safety or effectiveness.

#### Conclusion:

The information in this 510(k) submission demonstrates that the HeartSine Samaritan® PAD is substantially equivalent to the predicate device with respect to safety, effectiveness and performance and does not present any new issues of safety or effectiveness.

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Image /page/3/Picture/1 description: The image is a seal for the Department of Health & Human Services - USA. The seal is circular and contains the words "DEPARTMENT OF HEALTH & HUMAN SERVICES - USA" around the edge. In the center of the seal is an abstract image of an eagle.

Food and Drug Administration 9200 Corporate Boulevard Rockville MD 20850

MAY 2 5 2004

Mr. William J. Smirles NI. William J. Similes
Senior Vice President, Marketing & Business Development HeartSine Technologies, Inc. 940 Calle Amanecer, Suite E San Clemente, CA 92673

K041067 Re:

> Samaritan® PAD Regulation Number: 21 CFR 870.1025 Regulation Name: 27 Crice of Crice of Alarm Defibrillator, AED Regulatory Class: Class III Product Code: MKJ Dated: April 21, 2004 Received: April 30, 2004

Dear Mr. Smirles:

We have reviewed your Section 510(k) premarket notification of intent to market the ievices We have reviewed your Section 910(x) premainer is substantially equivalent (for the indications referenced above and have determined the actived predicate devices marketed in interstate for use stated in the encrosule) to regary mances prought the Medical Device Amendments, or to commerce provide way 20, 1970, the encordance with the provisions of the Federal Food. Drug. and Cosmetic Act (Act) that do not require approval of a premarket approval application (PMA). and Cosment ACT (ACC) that do not require appen of the general controls provisions of the Act. The You may, therefore, mance the device, seeject of the more
general controls provisions of the Act include requirements for annual registration, listing of general controls provisions of the tice, labeling, and prohibitions against misbranding and adulteration.

If your device is classified (see above) into either class II (Special Controls) or class III (PMA), it If your device is classified (see above) als. Existing major regulations affecting your device can may be subject to sueri additions, Title 21, Parts 800 to 898. In addition, FDA may be found in the Cours of reants concerning your device in the Federal Register.

Please be advised that FDA's issuance of a substantial equivalence determination does not mean r lease oc advisod that I Dr 3 tassance or our device complies with other requirements of the Act that I DA has mude a determissions administered by other Federal agencies. You must of any I cuttlar statutes and registments, including, but not limited to: registration and listing (21 CFR Part 807); labeling (21 CFR Part 801); good manufacturing practice requirements as set

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Page 2 -- Mr. William J. Smirles

forth in the quality systems (QS) regulation (21 CFR Part 820); and if applicable, the electronic form in the quality systems (Sections 531-542 of the Act); 21 CFR 1000-1050. product radiation control provisions (Seting your device as described in your Section 510(k) This ictir will anow you w to begin maing of substantial equivalence of your device to a legally prematication. The PDF Printation for your device and thus, permits your device to proceed to the market.

If you desire specific advice for your device on our labeling regulation (21 CFR Part 801), please If you desire specific advice 101 your as [phone]. Also, please note the regulation entitled, "Misbranding by reference to premarket notification" (21CFR Part 807.97). You may obtain other general information on your responsibilities under the Act from the Division of Small other general mionmational and Consumer Assistance at its toll-free number [phone] or [phone] or at its Internet address http://www.fda.gov/cdrh/dsma/dsmamain.html

Sincerely yours,

Neif Rr Ogden

Bram D. Zuckerman, M.D. Director Division of Cardiovascular Devices Office of Device Evaluation Center for Devices and Radiological Health

Enclosure

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Section

## Indications for Use

### 510(k) Number (if known): KU41067

Device Name: HeartSine Technologies, Inc. Samaritan® PAD

Indications for Use: The HeartSine Samaritan® PAD is indicated for use on victims of cardiac arrest who are exhibiting the following signs:

- Unconscious .
- Not breathing �
- Without circulation .

The Samaritan® PAD is intended for use by personnel who have been trained in its operation. Users should have received training in basic life support / AED, advanced life support or a physician-authorized emergency medical response training program. The Samantan® PAD is not currently indicated for use on children less than 8 years old.

#### (PLEASE DO NOT WRITE BELOW THIS LINE - CONTINUE ON ANOTHER PAGE)

Concurrence of CDRH, Office of Device Evaluation (ODE)

Neil R.P. Oslen for SDZ
(Division Sign-Off)
Division of Cardiovascular Devices

**510(k) Number** K041067

Prescription Use:

Over-the-Counter Use: or

HeartSine Technologies, Inc

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