As newer technologies have emerged and the experience has grown, percutaneous lead extraction has become the preferred method for removal of CIED hardware. However, these procedures involve significant risks, including cardiac tam- ponade, hemothorax, pulmonary embolism, lead migration, and death, even in experienced hands. Thus, the performance of these procedures should be limited to centers with the appropriate facilities and training, which includes the pres- ence and imminent availability of cardiothoracic surgery on site to provide backup in the event of complications. In high-volume centers, percutaneous lead removal can be accomplished relatively safely with a high rate of success.73 A primary surgical approach to lead removal in patients with CIED infection should be limited to patients who have significant retained hardware after attempts at percutaneous removal. Another scenario in which a preference for surgical lead removal has been advocated74 is in patients with lead vegetations 2 cm in diameter, because of concerns about the risk of pulmonary embolism with percutaneous lead extrac- tion. Experience suggests, however, that percutaneous re- moval in patients with large vegetations can be done without precipitating a clinically apparent pulmonary embolism.38,72 Until additional data are available, decisions regarding per- cutaneous versus surgical removal of leads with vegetations larger than 2 cm in diameter should be individualized and based on a patient s clinical parameters and the extractor s evaluation. Antimicrobial therapy is adjunctive in patients with CIED infection, and complete device removal should not be de- layed, regardless of timing of initiation of antimicrobial therapy. Selection of the appropriate antimicrobial agent should be based on identification and in vitro susceptibility testing results. Because the bulk of infections are due to staphylococcal species, and some of them will be oxacillin resistant, vancomycin should be administered initially as empirical antibiotic coverage until microbiological results are known. 