Background-Pacemaker pocket infection is a potentially serious problem after permanent pacemaker implantation. Antibiotic prophylaxis is commonly prescribed to reduce the incidence of this complication, but current trial evidence of its efficacy is conflicting. A large prospective randomised trial was therefore performed of antibiotic prophylaxis in permanent pacemaker implantation. The intention was firstly to determine whether antibiotic prophylaxis is efficacious in these patients and secondly to identify which patients are at the highest risk of infection. Methods-A prospective randomised open trial of flucloxacillin (clindamycin if the patient was allergic to penicillin) v no antibiotic was performed in a cohort of patients undergoing first implantation of a permanent pacing system over a 17 month period. Intravenous antibiotics were started at the time of implantation and continued for 48 hours. The trial endpoint was a repeat operation for an infective complication. Results-473 patients were entered into a randomised trial. 224 received antibiotic prophylaxis and 249 received no antibiotics. A further 183 patients were not randomised but were treated according to the operator's preference (64 antibiotics, 119 no antibiotics); these patients are included only in the analysis of predictors ofinfection. Patients were followed up for a mean (SD) of 19(5) months. Among the patients in the randomised group there were nine infections requiring a repeat operation, all in the group not receiving antibiotic (P = 0.003). In the total patient cohort there were 13 infections, all but one in the non-antibiotic group (P = 0.006).

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Retention of functionless pacemaker leads may occur following mechanical or infective problems (potentially or definitely infected) or after electrical failure of the lead. One hundred nineteen patients with a pacemaker lead (or leads) retained between 1970 and 1990 were reviewed retrospectively. Lead retention after an intervention dictated by potential or definite infection of the pacing system resulted in complications in 27 of 53 patients (51%), which in 22 patients (42%) were major (septicemia, superior vena cava syndrome, and further surgery under general anesthesia for recurrent "infective" problems) including three deaths. Complications were less likely if lead retention occurred after electrical failure with three minor and two major (surgery under general anesthesia, superior vena cava syndrome) complications in 66 patients (P less than 0.001). Bacteriology of swabs taken at the time of retention in the patients with potential or definite infection was unhelpful in predicting future complications: 8/18 patients (44%) whose swabs were negative had complications of which 5/18 (28%) were major. In our experience retention of functionless pacemaker leads after an intervention dictated by potential or definite infection of the pacing system, is associated with significant morbidity and mortality and should be avoided.

Permanent endocardial pacing in small children is feasible but is limited by two problems: sufficient extra lead has to be left within the heart to allow for growth and the excess has to be coiled behind the pacemaker, limiting the benefit from smaller generators. The required intravascular lead length in 120 children and adults was measured on posteroanterior chest X ray and was correlated with standing height. Measurements were made from the mid-point of the left clavicle to the apex of the right ventricle in a curve simulating the usual endocardial lead position. In 60 children, aged 2.0-15.9 years, intravascular lead length (range 15.5-29.0 cm) correlated well with height (0.83-1.70 m), r = 0.91. In 60 adults, mean age 54.9 years, intravascular lead length (25.5-35.6 cm) also correlated well with height (1.45-1.85 m), r = 0.71. In 20 adults the excess extravascular lead length, measured during pacemaker implantation via the subclavian route, was 15.1-33.7 cm and was inversely correlated with height. A child's eventual adult height can be predicted and, using our data, the extra length of lead necessary to allow for growth can be computed. Available endocardial pacing leads are usually 58- to 64-cm long. The excess extravascular lead is a major practical difficulty in children. Shorter leads would avoid the problem of excess lead and facilitate long-term pacing in small children.

Background-The report from the Working Party of the British Pacing and Electrophysiology Group recommends the use of more sophisticated pacemakers in most patients. These proposals were initially circulated in - September-1990 Conclusions The adoption of the recommendations of the British Pacing and Electrophysiology group in the Northern Region would greatly increase the cost of pacing hardware. The greater part of this increase would be attributable to the routine use of dual chamber pacing in patients with atrioventricular block and, the increased use of rate responsive units. The benefits of sophisticated pacing in a predominantly elderly population need to outweigh the disadvantages of the increased cost and complexity of follow up. (Br Heart J 1992;68:531-4)