Therefore, the suspicion of device- component infection must be balanced against the risk of surgical removal. An experienced team of physicians with expertise in cardiac electrophysiology, infectious diseases, pedi- atrics and congenital heart disease, and cardiothoracic surgery is pivotal in CIED infection management. Ethical Considerations Consideration for withdrawal of CIED support in terminally ill patients is common and will become more frequent as the age and accompanying comorbid conditions increase among recipi- ents of these devices. Although a thorough review of related ethical considerations is beyond the scope of the present state- ment, the topic is important to highlight, because the occurrence of a device infection has prompted some patients to refuse implantation of a new device after removal of an infected device. Many of the same ethical concerns that apply to deactivation of a noninfected implanted CIED apply to removal of an infected device without new CIED placement. The American College of Cardiology/American Heart Association/Heart Rhythm Society 2008 guidelines3 for device-based therapy of cardiac rhythm abnormalities outlines specific recommendations regarding terminal Figure 3. A and B, Nonthoracotomy ICD system placed in a 39-year-old man with inoperable pulmonary atresia with ventric- ular septal defect who had ventricular tachycardia with syncope. Note the retrosternal and intrapericardial coil arrays, the epicar- dial pace/sense leads, and the abdominal ICD. Table 3. Summary of Recommendations Recommendation Class and Level of Evidence A. Recommendations for diagnosis of CIED infection and associated complications 1. All patients should have at least 2 sets of blood cultures drawn at the initial evaluation before prompt initiation of antimicrobial therapy for CIED infection. IC 2. Generator-pocket tissue Gram stain and culture and lead-tip culture should be obtained when the CIED is explanted. IC 3. 