Antimicrobial prophylaxis is not recommended for dental or other invasive procedures not directly related to device manipulation to prevent CIED infection. (Level of Evidence: C) Emerging Technology Advances in molecular, gene, and cell therapies make the development of a biological pacemaker, a tissue that could be implanted in the heart, a future possibility.101 As pointed out in a recent report,102 our total dependence on a biological pacemaker will have to await the demonstration of the safety and long-term efficacy of the biological tissue. Advancement in the development of gene and cell-transfer therapies to restore myocardial function in a failing heart and to inhibit ventricular arrhythmias103,104 could potentially im- pact the need for ICDs in the future. Technical advances could also impact the risk of infection in cases in which a device, rather than a biological therapy, is required. These include development of a totally subcutaneous ICD and a leadless pacing system. Pediatric Concerns Pediatric and young adult patients with congenital heart disease represent a population with unique medical and surgical issues. These include smaller body size, vascular anomalies, congenital heart defects with and without surgical correction or palliation, and arrhythmias due to congenital disease or surgical repair. The decision to place a CIED in 1 of these patients requires long-term planning with the expec- tation of prolonged survival that will include numerous generator changes and lead replacement due to lead fracture or stress related to somatic growth. In addition, adults with some forms of congenital heart disease that do not allow traditional transvenous access to cardiac chambers will re- quire modified pacemaker/ICD systems. With that in mind, a variety of approaches to implantation of these systems are required. 