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Background The management of the recall is complicated by the competing risks of lead failure and complications that can occur with lead revision. Many of these patients are currently undergoing an elective generator change—an ideal time to consider lead revision. Objective To determine the cost-effectiveness of a proactive management strategy for the Sprint Fidelis recall. Methods We obtained detailed clinical outcomes and costing data from a retrospective analysis of 341 patients who received the Sprint Fidelis lead in British Columbia, where patients younger than 60 years were offered lead extraction when undergoing generator replacement. These population-based data were used to construct and populate a probabilistic Markov model in which a proactive management strategy was compared to a conservative strategy to determine the incremental cost per lead failure avoided. Results In our population, elective lead revisions were half the cost of emergent revisions and had a lower complication rate. In the model, the incremental cost-effectiveness ratio of proactive lead revision versus a recommended monitoring strategy was $12,779 per lead failure avoided. The proactive strategy resulted in 21 fewer failures per 100 patients treated and reduced the chance of an additional complication from an unexpected surgery. Conclusions Cost-effectiveness analysis suggests that prospective lead revision should be considered when patients with a Sprint Fidelis lead present for pulse generator change. Elective revision of the lead is justified even when 25% of the population is operated on per year, and in some scenarios, it is both less costly and provides a better outcome.

The greatest priority in treating atrial fibrillation (AF) is stroke prevention. There are now 3 main approaches to prevention: (1) oral anticoagulation (OAC), (2) eradication of AF, and (3) exclusion of the left atrial appendage (LAA) from the systemic circulation. The goal of this article is to review these approaches, with particular emphasis on nonpharmacologic methods and their role in light of current evidence. OAC is effective but is limited by major bleeding, physician and patient reluctance to use anticoagulants, and patient noncompliance. Eradication of AF with antiarrhythmic drugs has not been effective, and suppression with ablation has not yet been properly tested for stroke prevention. Finally, occlusion of the LAA is promising, but definitive evidence of efficacy for stroke prevention is lacking. Trials such as WATCHMAN LAA System for Embolic Protection in Patients With Atrial Fibrillation (PROTECT AF) and Prospective Randomized Evaluation of the WATCHMAN LAA Closure Device in Patients With Atrial Fibrillation vs Long-Term Warfarin Therapy (PREVAIL) provide the best quality evidence for LAA device closure, with results suggesting noninferiority to OAC. Surgical trials have yet to show the efficacy of LAA occlusion for stroke prevention. This review highlights the evidence behind each of these approaches and concludes that to date OAC remains the standard for stroke prevention in AF. Future trials will need to address novel OAC therapy when comparing them with LAA exclusion, and large randomized trials will be required to ascertain indications for nonpharmacologic therapy in current practice.