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Infants and small children with atrioventricular (AV) nodal disease frequently require pacing in order to maintain an adequate heart rate. The maintenance of AV synchrony is physiologically optimal in this setting. Unfortunately, small size and congenital anomalies often preclude the placement of standard transvenous dual chamber pacing systems. We report the case of a small child with a pre-existing dual chamber epicardial pacing system and subsequent ventricular lead dysfunction who underwent implantation of a new single chamber transvenous system which was programmed in VVT (triggered) mode in order to maintain AV synchrony.