With that in mind, a variety of approaches to implantation of these systems are required. Epicardial implants are frequently preferred or necessary because of a patient s size and growth potential, the presence of intracardiac shunts that allow the possibility of right-to-left shunting, and anatomic or surgical barriers to a transvenous approach. Biventricular pacing often requires epi- cardial placement of a left ventricular lead because of the small size of the coronary sinus. ICD implants are particularly chal- lenging in a patient who weighs less than 15 kg and usually require novel and nonstandard approaches with nonthoracotomy ICD coil arrays, epicardial patches, or shock leads placed in or adjacent to the pericardial space (Figures 3A and 3B). Another technique that is occasionally used to obtain the advantage of an endocardial lead while preserving the integrity of small veins is to perform a thoracotomy with placement of a lead through an atrial wall via a purse-string suture, with the lead connector extended to an abdominal device. Klug et al105 demonstrated that young patients with or without congenital defects have a greater prevalence of PPM lead infections than older ( 40 years of age) individuals. They speculated that several factors could be operative in causing an increased infection rate among younger patients, including a higher rate of reinterventions at the generator site, placement of a relatively larger device based on a higher ratio between the volume of the generator and body size, and the likelihood of local trauma to the generator site in younger, Baddour et al Cardiovascular Device Infections 469 more active individuals. 