VDD pacing provides the physiological benefits of atrioventricular synchronous pacing with the convenience of a single lead system, but is hampered by uncertainty regarding long term atrial sensing and potential development of sinus node disease. To examine the long-term reliability and complication rates of VDD pacing, we compared the outcome of 112 consecutive patients (age 70 +/- 13 years, 59% men) with symptomatic AV block who received a single pass bipolar VDD system, to 80 patients (age 63 +/- 16 years, 70% men) who received DDD pacing for the same indication. All patients were judged to have intact sinus node function based on submitted ECGs and monitoring results at the time of implant. Implant time was reduced in VDD patients compared to DDD patients (63 +/- 20 vs 97 +/- 36 minutes, P < 0.0001). Implant complications occurred in 5 (6%) DDD patients compared to 3 (3%) VDD patients (P = 0.15). The implant P wave was lower with VDD pacing compared to DDD patients (2.91 +/- 1.48 vs 4.0 +/- 1.7 mv, P < 0.0001), but remained stable during long-term follow-up in both groups. During 17.7 +/- 10.0 months of follow-up in the VDD group, only two VDD patients were reprogrammed to VVIR mode, compared to three DDD patients. Physiological atrioventricular activation was maintained in 94%-99% of beats throughout the follow-up period in the VDD group. VDD pacing is an excellent strategy for treatment of patients with symptomatic AV block. The lower cost, high reliability, and abbreviated implantation time suggest that VDD pacing is a viable alternative to DDD pacing in patients with high degree AV block and normal sinus node function.