Medtronic Model 5392 External Pulse Generator (EPG)

K162550 · Medtronic, Inc. · DTE · Oct 12, 2016 · Cardiovascular

Device Facts

• Record ID: K162550
• Device Name: Medtronic Model 5392 External Pulse Generator (EPG)
• Applicant: Medtronic, Inc.
• Product Code: DTE · Cardiovascular
• Decision Date: Oct 12, 2016
• Decision: SESE
• Submission Type: Special
• Regulation: 21 CFR 870.3600
• Device Class: Class 2
• Attributes: Therapeutic

Intended Use

The temporary pacemaker is used with a cardiac pacing lead system for temporary single or dual chamber pacing in a clinical environment by trained personnel. The temporary pacemaker can be used where short-term demand (synchronous) or asynchronous pacing is indicated for therapeutic, prophylactic or diagnostic purposes. The temporary pacemaker must be used in an environment where the patient is monitored continuously to ensure that it is operating properly and delivering appropriate therapy to the patient. Specific indications for temporary cardiac pacing include, but are not limited to, the following: Complete heart block; Sinus bradycardia; Sick sinus syndrome; Bradycardia with congestive heart failure; Atrial and/or ventricular arrhythmias; Cardiac arrest; Support, management, and evaluation of a patient prior to permanent pacemaker Implantation; Support during permanent pacemaker replacement; Cardiac complications during invasive or surgical procedures; Support following cardiac surgery; Acute myocardial infarction complicated by heart block; Atrial tachyarrhythmias that require high-rate burst pacing for treatment.

Device Story

Battery-powered, dual-chamber external pulse generator (EPG) provides temporary antibradycardia pacing. Used in clinical environments by trained personnel; requires continuous patient monitoring. Device connects to cardiac pacing lead system to deliver synchronous (demand) or asynchronous pacing therapy. Clinicians use device to manage heart block, bradycardia, arrhythmias, and surgical cardiac complications. Output affects clinical decision-making by providing life-sustaining or prophylactic pacing support. Optional disposable cover (53922) prevents accidental control activation. Modification involves updated internal cable routing and length to mitigate internal pinching of patient, battery, and LCD cables.

Clinical Evidence

Bench testing only. Qualification of the manufacturing process and design verification confirmed that the modified internal cable routing and length meet specifications and do not introduce new safety or performance risks.

Technological Characteristics

Battery-powered external pulse generator; dual-chamber pacing; includes patient, battery, and LCD cables. Modifications involve updated internal cable routing and length to mitigate pinching. Substantially equivalent to predicate in materials, design, and functionality.

Indications for Use

Indicated for patients requiring temporary single or dual chamber cardiac pacing for therapeutic, prophylactic, or diagnostic purposes, including complete heart block, sinus bradycardia, sick sinus syndrome, bradycardia with CHF, arrhythmias, cardiac arrest, pre/post-permanent pacemaker management, and surgical/post-surgical cardiac support.

Regulatory Classification

Identification

An external pacemaker pulse generator (EPPG) is a prescription device that has a power supply and electronic circuits that produce a periodic electrical pulse to stimulate the heart. This device, which is used outside the body, is used as a temporary substitute for the heart's intrinsic pacing system until a permanent pacemaker can be implanted, or to control irregular heartbeats in patients following cardiac surgery or a myocardial infarction. The device may have adjustments for impulse strength, duration, R-wave sensitivity, and other pacing variables.

Special Controls

*Classification.* Class II (special controls). The special controls for this device are:(1) Appropriate analysis/testing must validate electromagnetic compatibility (EMC) within a hospital environment. (2) Electrical bench testing must demonstrate device safety during intended use. This must include testing with the specific power source ( *i.e.,* battery power, AC mains connections, or both).(3) Non-clinical performance testing data must demonstrate the performance characteristics of the device. Testing must include the following: (i) Testing must demonstrate the accuracy of monitoring functions, alarms, measurement features, therapeutic features, and all adjustable or programmable parameters as identified in labeling; (ii) Mechanical bench testing of material strength must demonstrate that the device and connection cables will withstand forces or conditions encountered during use; (iii) Simulated use analysis/testing must demonstrate adequate user interface for adjustable parameters, performance of alarms, display screens, interface with external devices ( *e.g.* data storage, printing), and indicator(s) functionality under intended use conditions; and(iv) Methods and instructions for cleaning the pulse generator and connection cables must be validated. (4) Appropriate software verification, validation, and hazard analysis must be performed. (5) Labeling must include the following: (i) The labeling must clearly state that these devices are intended for use in a hospital environment and under the supervision of a clinician trained in their use; (ii) Connector terminals should be clearly, unambiguously marked on the outside of the EPPG device. The markings should identify positive (+) and negative (−) polarities. Dual chamber devices should clearly identify atrial and ventricular terminals; (iii) The labeling must list all pacing modes available in the device; (iv) Labeling must include a detailed description of any special capabilities ( *e.g.,* overdrive pacing or automatic mode switching); and(v) Appropriate electromagnetic compatibility information must be included.

Predicate Devices

• Medtronic Model 5392 External Pulse Generator (EPG) (K150246)

Submission Summary (Full Text)

{0}------------------------------------------------

DEPARTMENT OF HEALTH & HUMAN SERVICES

Public Health Service

Food and Drug Administration 10903 New Hampshire Avenue Document Control Center - WO66-G609 Silver Spring, MD 20993-0002

October 12, 2016

Medtronic, Inc. Brenna Loufek Associate Regulatory Affairs Specialist 8200 Coral Sea Street Ne Mounds View, Minnesota 55112

Re: K162550

Trade/Device Name: Medtronic Model 5392 External Pulse Generator (EPG) Regulation Number: 21 CFR 870.3600 Regulation Name: External Pacemaker Pulse Generator Regulatory Class: Class II Product Code: DTE Dated: September 12, 2016 Received: September 13, 2016

Dear Brenna Loufek:

We have reviewed your Section 510(k) premarket notification of intent to market the device referenced above and have determined the device is substantially equivalent (for the indications for use stated in the enclosure) to legally marketed predicate devices marketed in interstate commerce prior to May 28, 1976, the enactment date of the Medical Device Amendments, or to devices that have been reclassified in accordance with the provisions of the Federal Food, Drug, and Cosmetic Act (Act) that do not require approval of a premarket approval application (PMA). You may, therefore, market the device, subject to the general controls provisions of the Act. The general controls provisions of the Act include requirements for annual registration, listing of devices, good manufacturing practice, labeling, and prohibitions against misbranding and adulteration. Please note: CDRH does not evaluate information related to contract liability warranties. We remind you, however, that device labeling must be truthful and not misleading.

If your device is classified (see above) into either class II (Special Controls) or class III (PMA), it may be subject to additional controls. Existing major regulations affecting your device can be found in the Code of Federal Regulations, Title 21, Parts 800 to 898. In addition, FDA may publish further announcements concerning your device in the Federal Register.

Please be advised that FDA's issuance of a substantial equivalence determination does not mean that FDA has made a determination that your device complies with other requirements of the Act or any Federal statutes and regulations administered by other Federal agencies. You must comply with all the Act's requirements, including, but not limited to: registration and listing (21 CFR Part 807); labeling (21 CFR Part 801); medical device reporting (reporting of medical devicerelated adverse events) (21 CFR 803); good manufacturing practice requirements as set forth in

{1}------------------------------------------------

the quality systems (QS) regulation (21 CFR Part 820); and if applicable, the electronic product radiation control provisions (Sections 531-542 of the Act); 21 CFR 1000-1050.

If you desire specific advice for your device on our labeling regulation (21 CFR Part 801), please contact the Division of Industry and Consumer Education at its toll-free number [phone] or [phone] or at its Internet address

http://www.fda.gov/MedicalDevices/ResourcesforYou/Industry/default.htm. Also, please note the regulation entitled, "Misbranding by reference to premarket notification" (21 CFR Part 807.97). For questions regarding the reporting of adverse events under the MDR regulation (21 CFR Part 803), please go to

http://www.fda.gov/MedicalDevices/Safety/ReportaProblem/default.htm for the CDRH's Office of Surveillance and Biometrics/Division of Postmarket Surveillance.

You may obtain other general information on your responsibilities under the Act from the Division of Industry and Consumer Education at its toll-free number [phone] or [phone] or at its Internet address

http://www.fda.gov/MedicalDevices/ResourcesforYou/Industry/default.htm.

Sincerely,

M.A. Hillebrand

for

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

Enclosure

{2}------------------------------------------------

#### DEPARTMENT OF HEALTH AND HUMAN SERVICES Food and Drug Administration

### Indications for Use

510(k) Number (if known) K162550

#### Device Name

Medtronic Model 5392 External Pulse Generator (EPG)

#### Indications for Use (Describe)

The temporary pacemaker is used with a cardiac pacing lead system for temporary single or dual chamber pacing in a clinical environment by trained personnel. The temporary pacemaker can be used where short-term demand (synchronous) or asynchronous pacing is indicated for therapeutic, prophylactic or diagnostic purposes. The temporary pacemaker must be used in an environment where the patient is monitored continuously to ensure that it is operating properly and delivering appropriate therapy to the patient.

Specific indications for temporary cardiac pacing include, but are not limited to, the following:

- · Complete heart block
- · Sinus bradycardia
- · Sick sinus syndrome
- · Bradycardia with congestive heart failure
- · Atrial and/or ventricular arrhythmias
- · Cardiac arrest
- · Support, management, and evaluation of a patient prior to permanent pacemaker Implantation
- · Support during permanent pacemaker replacement
- · Cardiac complications during invasive or surgical procedures
- · Support following cardiac surgery
- · Acute myocardial infarction complicated by heart block
- · Atrial tachyarrhythmias that require high-rate burst pacing for treatment

Type of Use (Select one or both, as applicable)

Prescription Use (Part 21 CFR 801 Subpart D)

Over-The-Counter Use (21 CFR 801 Subpart C)

### CONTINUE ON A SEPARATE PAGE IF NEEDED.

This section applies only to requirements of the Paperwork Reduction Act of 1995.

#### *DO NOT SEND YOUR COMPLETED FORM TO THE PRA STAFF EMAIL ADDRESS BELOW *

The burden time for this collection of information is estimated to average 79 hours per response, including the time to review instructions, search existing data sources, gather and maintain the data needed and complete and review the collection of information. Send comments regarding this burden estimate or any other aspect of this information collection, including suggestions for reducing this burden, to:

> Department of Health and Human Services Food and Drug Administration Office of Chief Information Officer Paperwork Reduction Act (PRA) Staff PRAStaff(@fda.hhs.gov

"An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB number."

{3}------------------------------------------------

# 510(k) Summary

[As required by 21 CFR 807.92]

| Date Prepared: | October 11, 2016 |
|--------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Submitter: | Medtronic, Inc.<br>Medtronic Cardiac Rhythm Heart Failure<br>8200 Coral Sea Street N.E.<br>Mounds View, MN 55112<br>Establishment Registration Number: 2182208 |
| Contact Person: | Brenna Loufek<br>Associate Regulatory Affairs Specialist<br>Medtronic Cardiac Rhythm Heart Failure<br>Phone: [phone]<br>Fax: [phone]<br>Email: [e-mail] |
| Alternate Contact: | Rachel Libi<br>Senior Regulatory Affairs Manager<br>Medtronic Cardiac Rhythm Heart Failure<br>Phone: [phone]<br>Fax: [phone]<br>Email: [e-mail] |

# General Information

| Trade Name: | Medtronic Model 5392 External Pulse Generator (EPG) |
|-----------------------|-----------------------------------------------------------------------------------------|
| Common Name: | External pacemaker pulse generator |
| Regulation Number: | 21 CFR 870.3600 |
| Product Code: | DTE |
| Classification: | Class II (As per Final Order published 18-APR-2016 by FDA docket<br>number 2011-N-0650) |
| Classification Panel: | Cardiovascular |
| Special Controls: | Not applicable |
| Predicate Devices: | Medtronic Model 5392 External Pulse Generator (EPG) K150246 |

{4}------------------------------------------------

# Device Description

The Model 5392 EPG is a battery-powered, dual chamber, temporary pacemaker designed primarily for temporary antibradycardia pacing therapy. The 53922 EPG cover accessory is an optional disposable protective cover to reduce accidental activation of the controls of the 5392 EPG.

# Indications for Use

The temporary pacemaker is used with a cardiac pacing lead system for temporary single or dual chamber pacing in a clinical environment by trained personnel. The temporary pacemaker can be used where short-term demand (synchronous) or asynchronous pacing is indicated for therapeutic, prophylactic or diagnostic purposes. The temporary pacemaker must be used in an environment where the patient is monitored continuously to ensure that it is operating properly and delivering appropriate therapy to the patient.

Specific indications for temporary cardiac pacing include, but are not limited to, the following:

- . Complete heart block
- . Sinus bradycardia
- Sick sinus syndrome ●
- Bradycardia with congestive heart failure
- Atrial and/or ventricular arrhythmias ●
- Cardiac arrest ●
- . Support, management, and evaluation of a patient prior to permanent pacemaker Implantation
- Support during permanent pacemaker replacement .
- Cardiac complications during invasive or surgical procedures .
- . Support following cardiac surgery
- . Acute myocardial infarction complicated by heart block
- Atrial tachyarrhythmias that require high-rate burst pacing for treatment .

### Technological Characteristics

Intended use, design, materials, performance and technological characteristics are substantially equivalent to the predicate devices referenced.

### Technological Characteristics

When compared to the predicate device (K150246), the modified Medtronic Model 5392 External Pulse Generator presented in this submission has the same:

- Intended use/indications for use ●
- Operating principle
- . Design features

{5}------------------------------------------------

- Device functionality ●
- Biological safety
- Packaging materials ●
- Shelf life

The modified Model 5392 EPG and the predicate device differ in the following:

- Modified routing and length of three internal cables ●
## Substantial Equivalence and Summary of Studies:

Technological differences between the subject and predicate devices have been evaluated with devices manufactured with the updated cables and new routing. The data from the newly qualified process shows that the devices could be manufactured with minor enhancements to the design specifications to mitigate internal pinching of the Patient Cable, Battery Cable, and LCD Cable.

The modified Medtronic Model 5392 External Pulse Generator is substantially equivalent to the specified predicate device based on comparisons of the device functionality, technological characteristics, and indications for use. The device design and materials have been verified through the following:

- Qualification of the manufacturing process, including new fixtures ●
### Conclusion:

The results of the above qualification met the specified acceptance criteria and did not raise new safety or performance issues. Therefore, the modifications made to the Medtronic Model 5392 External Pulse Generator described in this submission result in a device that is substantially equivalent to the predicate.