Simultaneously, dual-chamber pacing has become used much more frequently than single-chamber pacing.4 Similarly, the frequency of ICD implantation increased in the elderly (70 to 79 years of age) and very elderly (80 years of age or older).5 The 2001 World Survey7 found that in developed countries, between 20% and 35% of CIED recipients were more than 80 years old. The National Hospital Discharge Survey8 found a 49% increase in the number of new CIED implantations, including both PPMs and ICDs, in the United States between 1999 and 2003. In 2003, although the absolute number of PPM implan- tations was higher than for ICDs (180 284 versus 57 436), more of the increase in CIED device implantation was driven by ICD implantations (160% and 31% increases in ICD and PPM implantations, respectively).8 In summary, the increased rates of CIED implantation coupled with increased implan- tation in older patients with more comorbid conditions have set the stage for higher rates of CIED infection. Incidence and Epidemiology PPM endocarditis has been recognized since the early 1970s.9,10 In earlier years, the rates of PPM infection ranged widely between 0.13%11 and 19.9%.12 Although most infec- tions have been limited to the pocket, frank PPM endocarditis accounts for approximately 10% of PPM infections.13 The first ICD was implanted in 1980.14 Subsequent de- creases in the size of ICDs permitted implantation without thoracotomy, although initially, abdominal implantation with tunneling was required. Subsequently, the entire device could be implanted prepectorally. The infection rate with these less extensive operations was lower ( 7%).15 In a study of all ICD primary implantations, replacements, and revisions at a single center, there were 21 ICD-related infections (1.2%) among 1700 procedures, affecting 1.8% of 1170 patients. 