A survey of implanters of permanent cardiac pacemakers and implanted cardioverter-defibrillators (ICDs) in the United States during 1993 was conducted to identify present and changing patterns in indications for pacing implantation techniques, pacing-mode selection, follow-up, and opinions regarding pacing-and ICD-related issues. Five major pacemaker manufacturers also provided estimates of the numbers of pacemakers and ICDs implanted in the United States from 1990 through 1993. In 1993 approximately 133,000 new rhythm-management devices, including 112,000 primary pacing systems and 16,000 ICDs, were implanted, an increase of 18% for pacemakers and 113% for ICDs since 1990. In 1993, pacemaker implantations were performed by about 8,700 physicians working in 3,300 hospitals and 1,000 independent "surgi-centers." Since the last survey, which addressed pacing practices in 1989, respondents' use of dual-chamber pacemakers increased from 32% to 68% of the total, and adaptive-rate systems from 29% to 48%. Significant differences (p <0.05) were found among subcategories of implanters and among complications encountered in different circumstances. Surgeons tended be the older and more experienced implanters, but used a smaller proportion of active-fixation leads, dual-chamber systems, and adaptive-rate pulse generators, and tended to rely more heavily on a pacemaker manufacturer's representative in operative and follow-up procedures. Complications were more common with bipolar leads, with leads implanted by means of an introducer, and with passive-fixation ventricular leads. The survey provided useful insights into trends and differences in pacemaker and defibrillator practice. Future surveys would be facilitated if a standardized implant registry such as that used in Europe were established in the United States.