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Boston Scientific Recalls Ingenio Pacemakers and CRT-Ps

Graphic by Amanda Pedersen/MD+DI Ingenio recall
Boston Scientific said its Ingenio pacemakers and cardiac resynchronization therapy pacemakers (CRT-Ps) run the risk of incorrect transition to safety mode. In safety mode, there is a risk of inappropriate loss of pacing.

Boston Scientific is recalling Ingenio family of pacemakers (includes models Advantio DR EL, Ingenio DR EL, and Vitalio DR EL) and cardiac resynchronization therapy pacemakers (CRT-Ps) due to the risk of incorrect transition to safety mode.

Safety mode is intended to provide backup if the device is faulty, the company said, but in safety mode, there is a risk of inappropriate loss of pacing due to sensing of muscle contractions. If the Ingenio pacemaker or CRT-P incorrectly goes into safety mode, the device cannot be reprogrammed and must be replaced. 

According to the FDA notice, the recall includes 48,000 devices that were distributed between November 2011 and August 2020. There have been 65 reported incidents, including three injuries which required patients to receive temporary external pacing. There have been no reports of death.

Image courtesy of FDABoston Scientific Ingenio recall

What to do if your patient has an Ingenio pacemaker or CRT-P

On June 3, Boston Scientific sent all affected customers an important medical device advisory. The letter requested customers to:

  • When assessing potential risk for a patient if their device incorrectly transitions to safety mode, consider patient-specific factors (which may vary over time), including underlying health issues, pacemaker dependence, or problems with pacing.
  • If a device incorrectly enters safety mode, schedule replacement. Boston Scientific does not recommend preventive replacement for affected devices. However, for individual patients, factors such as those listed above in the previous bullet and shared decision-making may support consideration of early device replacement to prevent unintended outcomes. In these cases, the following guidance should be considered:
    • For EL pacemakers, if early replacement is planned, schedule replacement when the service life of the device is four years (or less, if the device currently indicates fewer than four years remaining).
    • For CRT-Ps, if early replacement is planned, schedule replacement when the service life of the device remaining is three years (or less, if the device currently indicates fewer than three years remaining).
  • Perform a system follow-up remotely or in person at least every 12 months. For patients who may not require early device replacement, continue with existing follow-up procedures until there is one year of service life expected and then follow-up every three months until replacement (as indicated in the device’s instructions for use).
  • For each patient with an affected device, add the company's physician letter sent on June 3, to their medical record to maintain awareness of this topic for the remaining service life of the device.
  • Report adverse events experienced with these devices to Boston Scientific or FDA’s MedWatch Adverse Event Reporting program.
  • Return explanted devices to Boston Scientific. A no-cost return product kit is available from your local Boston Scientific representative. This kit is also available at no charge through Boston Scientific's customer service department at 1-800-CARDIAC (227-3422) or 651-582-2698.
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