Received: 17 September 2023 | Revised: 27 September 2023 | Accepted: 10 October 2023

DOI: 10.1111/jce.16113

INVITED REVIEW

Very high‐power short‐duration catheter ablation

for treatment of cardiac arrhythmias: Insights from the
FAST and FURIOUS study series

Christian‐H. Heeger MD, FESC, FEHRA, FHRS1,2 | Karl‐Heinz Kuck MD1,2 |

Roland R. Tilz MD1,2

1
Department of Rhythmology, University
Hospital Schleswig‐Holstein, University Heart Abstract
Center Lübeck, Lubeck, Germany
The QDOT MICRO™ Catheter is a novel open‐irrigated contact force‐sensing
2
German Center for Cardiovascular Research
(DZHK), Partner Site Hamburg/Kiel/Lübeck,
radiofrequency ablation catheter. It offers very high‐power short‐duration (vHPSD)
Lübeck, Germany ablation with 90 W for 4 s to improve safety and efficacy of catheter ablation
procedures. Although the QDOT MICRO™ Catheter was mainly designed for
Correspondence
Christian‐H. Heeger, MD, FESC, FEHRA, pulmonary vein isolation (PVI) its versatility to treat atrial fibrillation (AF) and other
FHRS, Department of Rhythmology, types of arrhythmias was recently evaluated by the FAST and FURIOUS study series
Universitätsklinikum Schleswig‐Holstein
(UKSH), University Heart Center Luebeck, and other studies and will be presented in this article. Available study and registry
Ratzeburger Allee 160, Luebeck D‐23538, data as well as case reports concerning utilization of the QDOT MICRO™ Catheter
Germany.
Email: christian.heeger@gmx.net for the treatment of cardiac arrhythmias including AF, focal and macroreentry atrial
tachycardia, typical atrial flutter by cavotricuspid isthmus block, premature
Disclosures: Christian‐H. Heeger received
travel grants and research grants from ventricular contractions, and accessory pathways were reviewed and summarized.
Boston Scientific, LifeTech, Biosense Webster, In summary, the QDOT MICRO™ Catheter showed safety and efficacy for PVI and is
and Cardiofocus and speaker honoraria from
Boston Scientific, Biosense Webster, Cardio- able to treat also other types of arrhythmias as is was recently evaluated by case
focus, and C.T.I. GmbH and Doctrina Med. reports and the FAST and FURIOUS studies.
Karl‐Heinz Kuck reports grants and personal
fees from Abbott Vascular, Medtronic, and
Biosense Webster outside the submitted KEYWORDS
work. Roland R. Tilz is a consultant for Abbott, atrial fibrillation, premature ventricular contractions, pulmonary vein isolation, radiofrequency,
Boston Scientific, Biotronik, and Biosense very high‐power short‐duration
Webster and received speaker honoraria from
Biosense Webster, Medtronic, Boston Scien-
tific, and Abbot Medical.

1 | INTRODUCTION Pulmonary vein isolation (PVI) by catheter ablation has shown

Catheter ablation is a safe and effective treatment strategy of cardiac
arrhythmias and is increasingly performed worldwide.1 Beside the
fact that cardiac arrhythmias are very versatile atrial fibrillation (AF) is
the most common form which affects increasing numbers of
patients.1
high success rates for the treatment of paroxysmal (PAF) and
persistent AF (PersAF). Novel single‐shot ablation devices imple-
menting diverse energy sources (cryothermal, laser, pulse field
ablation [PFA], radiofrequency [RF]) have shown excellent acute
and long‐term success rates with decreased procedure time
compared to RF‐based three‐dimensional (3D) mapping and point‐

The paper is based on the presentation at the 2023 European Cardiac Arrhythmia Society (ECAS) 16th Annual Congress held in Paris, France, in March 2023.

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2023 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.

J Cardiovasc Electrophysiol. 2023;1–10. wileyonlinelibrary.com/journal/jce | 1


2 |
by‐point PVI.2–10 Due to the fact that single‐shot devices are mainly
designed for PVI they have several limitations concerning versatility,
11–14
flexibility, and adaptability to different anatomies.
Recently 3D mapping and point‐by‐point based catheter ablation
achieved several improvements by implementing contact force (CF),
ablation index (AI), or lesion size index (LSI) guided RF ablation which
have been shown to decrease procedure time, improving safety and
15,16
patient outcomes. Latest achievements are high‐power short‐
duration (HP‐SD) ablation with a maximum of 50 W and very HPSD
(vHPSD) ablation with maximum of 70–90 W which have been
17–22
introduced to clinical practice. In CF‐guided ablation procedures
power is limited to 50 W,23,24 while in a power‐controlled ablation
mode without CF sensing catheter power is limited to 70 W.18,25
Although these concepts seem to be safe and effective, no real‐time
temperature monitoring is possible because conventional catheters
were utilized in those studies.18,23–25
However, it has been shown that real‐time subendocardial tissue
temperature monitoring during RF energy delivery is a direct
indicator of lesion formation but measurements by temperature
sensors embedded in the catheter tip have been shown to be not an
accurate indicator of actual tissue temperature.26,27
1.1 | QDOT MICRO™ catheter
To overcome those issues a novel ablation catheter was recently
introduced. The QDOT MICRO™ Catheter (Biosense Webster, Inc.)
is an open‐irrigated CF sensing single‐tip catheter (Figure 1). The
QDOT MICRO™ Catheter incorporates three microelectrodes and
six miniature thermocouples (1 mm in diameter [3 proximal and
3 distal]), at its tip for precise temperature monitoring.17,28,29 The
thermocouples are embedded at distinct locations within the outer
metal shell of the catheter, just 75 μm underneath the tip surface.
The reason for this superficial location design was to obtain more
accurate local temperature measurements from the catheter tip
which is in direct contact with the tissue, in comparison to the
conventional tip temperature measurements, that is, altered by the
F I G U R E 1 QDOT MICRO™ Catheter. Picture of the QDOT
MICRO™ Catheter tip showing microelectrode at the tip. The black
arrows highlight one microelectrode, the contact force sensor and
the 56 irrigation holes at the catheter tip. Source: Property of
C. Heeger.
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HEEGER ET AL.
cooler parts of the tip that are not in touch with the tissue.26 It has
been developed allowing for real‐time catheter‐to‐tissue interface
temperature measurements. Therefore, a real temperature‐
controlled catheter ablation with automatic adjustment of power
and irrigation output based on real‐time temperature measurement
is achieved which allows for safe and effective RF‐lesion
formation.29,30 The novel “bulls eye” tool of Carto™ offers real‐
time visualization of the temperature controlled ablation. Further-
more, catheter stability and contact is visualized by the tool
(Supporting Information: Video 1).
The QDOT MICRO™ Catheter offers two different ablation
modes.
In QMODE (conventional temperature‐controlled ablation mode
with a maximum of 50 W) the system adjusts (1) the irrigation flow
rate and (2) power based on the measured temperature to stabilize
the catheter tip temperature within the allowed temperature range
avoiding over‐heating and steam‐pop. Lesions formation is guided by
AI in the QMODE and is individualizable concerning power and
ablation duration.
In QMODE+ (vHPSD mode, 90 W/4 s) only power is adapted to
adjust the target temperature.30 The target temperature of the
temperature‐controlled ablation is usually 60°C based on the hottest
surface thermocouple. The irrigation flow rate delays the energy
application for a minimum of 2 s before and 4 s after each RF
application. It is always possible to stop the lesion formation, however,
in QMODE+ it is only possible to ablate with 90 W for a maximum of
4 s. The default irrigation setting is set at 2 and 8 mL/min with a
recommended CF working ranges 5–30 g.
The vHPSD strategy aims to create shallower but wider lesions in
a very short time by reducing conductive heating and increasing
resistive heating at the same time. Additionally, collateral tissue
damage might be reduced.28,31
26
The three microelectrodes at the catheter tip of the QDOT
MICRO™ Catheter offer sharp potentials and a higher resolution
during mapping.29 Previous analyses provided evidence for reduced
RF ablation time and procedure duration while showing a good safety
profile in comparison to conventional power‐controlled ablation.11,30
Although the QDOT MICRO™ Catheter was mainly designed for PVI
its versatility to treat other types of arrhythmias was recently
evaluated and will be presented in this article (Tables 1 and 2).
2 | B IO PH Y S I C S O F V H P S D RF AB L A T I O N
During vHPSD ablation, myocardial lesions are created by a greater
amount of resistive (direct) rather than conductive (indirect) heating
when compared with conventional ablation settings. Therefore,
vHPSD may result in more effective, broader, and superficial lesion
formation potentially avoiding collateral damage to adjacent struc-
tures like the esophagus and the phrenic nerve. In preclinical models,
vHPSD ablation has shown improved atrial linear lesion contiguity,
transmurality, and durability and has substantially reduced RF
ablation times.
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HEEGER ET AL. | 3

TABLE 1 Studies on QDOT MCRO ablation catheter.

# Patients,
Study, references Type of study catheter Main findings Status, year

QDOT‐FAST Prospective, multicenter 52 QDOT Mean procedure time: 105.2 ± 24.7 min Published, 2018
Reddy et al.30 (4), single arm (vHPSD) RF ablation time: 8.1 min.
No severe adverse events

FAST and FURIOUS Prospective, single‐ 28 QDOT Median procedure duration: Published, 2021
AFTilz et al.17 center, (vHPSD) vHPSD 55 min (IQR: 48–60) versus control: 105 min
matched (STSF) 28 STSF (IQR: 92–120, p < .0001).
40 W Median RF time:
vHPSD: 338 s (IQR: 286, 367) versus control: 1580 s
(IQR: 1350, 1848), p < .0001)
No differences in periprocedural complications

FAST and Prospective, single‐ 50 QDOT Mean RF time: 352 ± 81 s (vHPSD) versus 1657 ± 570 s Published, 2021
FURIOUS PVI center, (vHPSD) (control, p < .0001).
Heeger et al.11 matched (STSF) 50 STSF Mean procedure duration: 59 ± 13 min (vHPSD) versus
40 W 101 ± 38 min. (control, p < .0001).
First pass isolation rate: 74% (vHPSD) versus 76%
(control, p = .817).
Severe adverse events: 2% (vHPSD) versus 6%
(control, p = .307).
12‐month recurrence‐free survival was 78% (vHPSD)
versus 64% (control, p = .142).

Q‐FFICIENCY Prospective, multicenter 166 QDOT Median procedural time: Published, 2023
Osorio et al.32 (n = 22), (vHPSD) 132 min
nonrandomized Median RF time: 8.0 min
Primary adverse event rate: 3.6%.
12‐month success rate: 76.7%.

POWER PLUS Prospective, 180 (1:1) Median procedural time: 70 (60, 80) min versus 75 Published, 2023
O'Neil et al.33 Multicenter (4), 90 vHPSD (65, 88.3) min; p = .009).
randomized 90 35/50 W First‐pass isolation: vHPSD group (83.9% vs. 90%
controlled trial control; p = .0852).
90 W versus 35/50 W No major complications
No differences for 6‐months outcome, p = .681

FAST and Prospective, single‐ 24 (QDOT) Median RF time: 52 (16, 156) s (QDOT) versus 350 (240, Published, 2022
FURIOUS PVC center, matched vHPSD 442) s (control, p < .0001).
Heeger et al.34 24 (STSF) No difference for procedure duration (p = .489.
67% patients (QDOT) the acute endpoint was achieved by
using vHPSD only (RVOT: 92%, LVOT 42%).
Severe adverse events (4%, QDOT, 8%, control, p = .551)
No differences for 6‐months follow‐up (p = .712)

FAST and Prospective, single‐ 25 (QDOT) n.a. Ongoing

FURIOUS CTI center, matched vHPSD
25 (STSF)

Schilaci et al.35 Retrospective, single‐ 28 (QDOT) Procedure time (30 ± 4 min vs. 34 ± 10 min, p = .5) Published, 2022
center, consecutive vHPSD RF time (88 ± 40 vs. 492 ± 269 s, p < .001)
First pass rate: 89% versus 93%, p = .59

Sohns et al.36 Prospective, single center 60 (QDOT) MRI data on PVI durability: Published, 2021
vHPSD RPVs: 76.7% LPVs: 76.7%
RPV and LPV: 66.7%

FAST and Prospective, single‐ 25 (QDOT) n.a. Ongoing

FURIOUS Redo center, matched vHPSD

peQasus Retrospective registry, >500 (QDOT) n.a. Ongoing

multicenter ClinicalTrials.gov ID
NCT05710822

Abbreviations: IQR, interquartile range; PVI, pulmonary vein isolation; RF, radiofrequency; vHPSD, very high‐power short‐duration.
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4 | HEEGER ET AL.

TABLE 2 Case reports on QDOT MICRO Ablation catheter.

References Arrhythmia Catheter, mode Main finding Status, year

37
Eitel et al. Left lateral accessory pathway QDOT, vHPSD Safety and feasibility, with vHPSD only Published, 2022
38
Heeger et al. Premature ventricular contractions QDOT, vHPSD Safety and feasibility, with vHPSD only Published, 2021
39
Heeger et al. Left atrial macroreentry tachycardia QDOT, vHPSD Safety and feasibility, with vHPSD only Published, 2021

Fink et al.40 Inappropriate sinus tachycardia QDOT, vHPSD Safety and feasibility, with vHPSD only Published, 2022

Abbreviation: vHPSD, very high‐power short‐duration.

F I G U R E 2 QDOT MICRO™ Catheter during pulmonary vein isolation in QMODE+. (A) Three‐dimensional electroanatomic reconstruction
(CARTO 3, UNIVIEW module, Biosense Webster) of the left atrium in PA view and (B) superior view. Please note the circle depicted through red‐
black tags created by radiofrequency ablation utilizing the QDOT MICRO™ Catheter in the QMODE+ ablation mode. The data of the current
application is depicted in (C) and shows the biophysics parameters of a very‐high‐power short‐duration ablation by 90 W/4 s. The parameters of
power (W) Impedance (Ω), temperature (°C), and contact force (g) are shown. Right upper corner depicts the bulls eye view with temperature
measurements of the QDOT MICRO™ Catheter tip. Source: Property of C. Heeger.

The safety profile has been shown to be similar to those of
standard moderate power and moderate duration irrigated RF
ablation.30 vHPSD in combination with temperature‐controlled
ablation enables the ablation to stabilize the catheter tip temperature
within the target temperature range and is avoiding over‐heating and
steam‐pops.
3 | PULMONARY VEIN ISOLATION
U T I L I Z I N G T H E Q D O T M I C R O™ CATHE TER
With the ability to perform temperature‐controlled ablation in combina-
tion with vHPSD the QDOT MICRO™ Catheter is an ideal tool for thin‐
walled LA procedures especially for PVI (Figure 2). The vHPSD strategy
aims to create shallower but wider lesions in a very short time by
reducing conductive heating and increasing resistive heating at the same
time.17 Additionally, collateral tissue damage might be reduced.28 Utilizing
conventional power‐controlled moderate‐power long‐duration RF appli-
cations the “close—protocol” with an interlesion distance (ILD) of 6 mm
has been introduced and verified for PVI.41 Lesion formation of vHPSD
applications creates wider but shallower lesions. To achieve continuous
lesions, we recently adapted the close‐protocol to an individualized and
tighter “very close‐protocol.” Utilizing the “very close‐protocol” an ILD of
3–4 mm at anterior aspect and ILD of 5–6 mm at the posterior aspect of
the LA using vHPSD only is performed and safety, efficacy, and follow‐up
in comparison to conventional CF sensing AI‐guided RF ablation has been
shown in the FAST and FURIOUS AF and FAST and FURIOUS PVI
studies.11,17
FAST and FURIOUS PVI study was a prospective nonrandomized
trial that compared 50 AF patients (vHPSD group) treated by PVI
with the QDOT MICRO™ Catheter in QMODE+ only versus 50
previous patients (control group) with conventional point‐by‐point RF
40 W AI‐guided ablation by the THERMOCOOL SMARTTOUCH
SOURROUND FLOW ablation catheter (Biosense Webster). In both
groups, patients with PAF and PersAF have been treated.
For patients of the vHPSD group, the QMODE+ was exclusively
used for all procedures. No switch to QMODE was necessary to
achieve PVI. No differences were observed between the groups
concerning catheter maneuverability and catheter stability. Here a
significantly reduced mean RF time of 352 ± 81 s (vHPSD) versus
1657 ± 570 s (control, p < .0001) was observed. Furthermore, the
mean procedure duration was 59 ± 13 (vHPSD) and 101 ± 38 (control,

HEEGER ET AL.
p < .0001) and the first pass isolation rate was 74% (vHPSD) and 76%
(control, p = .817). Severe adverse events were reported in 2%
(vHPSD) and 6% (control, p = .307) and the 12‐month recurrence‐free
survival was 78% (vHPSD) and 64% (control, p = .142). In conclusion,
PVI solely utilizing vHPSD via a very close protocol was shown to
provide safe and effective PVI with a high rate of first‐pass isolations.
No steam pops and no catheter tip charring were detected. An
esophageal temperature probe was utilized in all vHPSD patients. A
temperature of >38.5°C was detected in 18 (36%) patients solely at
the posterior part of the left PVs. The mean maximum esophageal
temperature was measured at 42 ± 2°C. No clinical apparent
esophageal lesions and no atrio‐esophageal fistulas were found.11
The QDOT‐FAST trial was a first‐in‐human, prospective,
multicenter, single‐arm, clinical study of the QDOT MICRO™
Catheter conducted in four European countries (Austria, Belgium,
Czech Republic, and Italy). It evaluated the safety and short‐term
performance of the QDOT MICRO™ Catheter in QMODE+ for PVI in
52 PAF patients. The total procedure and fluoroscopy times were
105.2 ± 24.7 and 6.6±8.2 min, respectively. The total RF ablation time
was 8.1 min. The longer procedure time compared to the FAST and
FURIOUS PVI study might be explained by the fact that in only 78.8%
of cases (41 of 52), PVI was achieved using the QMODE+ only. No
30
severe adverse events occurred in this study.
The Q‐FFICIENCY trial was a prospective, multicenter (n = 22),
nonrandomized study that aimed to evaluate the safety and
effectiveness of the QDOT MICRO™ Catheter in treating drug‐
refractory, symptomatic PAF patients (n = 166) utilizing vHPSD only.
The median procedural duration was 132 min and the median RF time
was 8.0 min while the primary adverse event rate was 3.6%. The
12‐month clinical success rate was 76.7%. Although the findings
concerning safety and effectiveness were similar to the FAST and
FURIOUS PVI study the procedure time was almost doubled which
could be the consequence of its multicenter character with some
32
centers unexperienced in QDOT MICRO™ Catheter procedures.
The POWER PLUS trial was a multicenter, randomized controlled
trial, the authors compared procedural efficiency, efficacy, and safety
of PVI using 90‐W/4‐s ablation to 35/50‐W ablation. The procedural
time was shorter in the 90‐W group vs the 35/50‐W group[median
70 (60, 80) min vs. median 75 (65, 88.3) min; p = .009]. No major
complications were observed in both groups with esophageal injury
occurring in one patient per group.
A nonsignificant trend towards lower rates of first‐pass isolation
was seen in the 90‐W group (83.9% vs. 90%; p = .0852). However, no
differences in 6‐month outcomes were observed. The authors
suggest to test a hybrid approach combining QMODE+ for anterior
and QMODE for posterior aspects of the LA in future studies.33
Although rare atrio‐esophageal fistula after catheter ablation of
42
AF is a devastating and potentially lethal complication. The fact that
vHPSD applications create shallower and wider lesions might be a
factor for preventing atrio‐esophageal fistulas. A recent study of
90 consecutive patients treated by vHPSD‐based PVI underwent
postablation esophageal endoscopy. None of the 90 patients
demonstrated esophageal ulceration (0%) which might support the
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| 5
abovementioned positive effect of the lesion formation in the
prevention of esophageal lesions. Furthermore, no steam pop, cardiac
tamponade, stroke, or fistula was reported in this study.43 Although
the rate of clinical apparent stroke and TIA is reported to be low
initial cerebral magnetic resonance imaging (MRI) data after
QMODE+ based PVI showed silent cerebral lesions in 6/23 (26%)
patients. Since coagulation on the catheter tip was detected at the
end of the procedure suggesting this observation to being related to
those events.19,44 Therefore, the RF generator software has been
recently modified aiming to reduce the rate catheter tip coagulation.
Recently, data on durability was assessed by cardiac MRI in 60
patients treated by vHPSD. Here complete PV encirclement was
observed in 76.7% for RPVs, in 76.7% for LPVs, and in 66.7% for both
PV pairs.36 These findings are promising and are in line with findings
assessed in the FAST and FURIOUS PVI study. Here PVI durability
assessed during redo‐procedures was 75% (vHPSD) versus 33%
(control, p < .001).11 The FAST and FURIOUS REDO study is ongoing
and will present data of PVI durability after initial vHPSD very close
protocol‐based PVI.
The available data of the QDOT MICRO™ Catheter for PVI is
promising. While demonstrating a good safety profile, the total
ablation time, and procedural duration, were impressively low
utilizing vHPSD. The retrospective peQasus study (clinical trials.gov:
ID: NCT05710822, vHP‐SD ablation utilizing the QDOT MICRO™
Catheter for pulmonary vein isolation—a multicenter study) will
evaluate safety and efficacy of the QDOT MICRO™ Catheter for PVI
in multiple centers in Europe in a large group of >500 patients.
3.1 | QDOT MICRO™ catheter for cavotricuspid
isthmus (CTI) ablation
Beside the fact that QDOT MICRO™ Catheter QMODE+‐based ablation
for PVI has been evaluated in several trials and studies, there is only
limited data for catheter ablation of the CTI in patients presenting with
typical atrial flutter (AFL) (Figure 3). The main concern about vHPSD is the
lack of transmurality in regions with thicker tissue like the CTI.45
However, data utilizing 50 W in studies by Kwon et al. and Yavin et al.
reported a success rate for CTI block of 100%.46,47
Schillaci et al. evaluated vHPSD ablation of the CTI in 28
consecutive patients (FAST) and compared the data to the last 30
consecutive patients who, previously, underwent CTI ablation by
STSF guided by AI (control). For both groups an ILD of ≤6 mm was
aimed. The vHPSD ablation was as effective as AI‐guided ablation in
achieving acute CTI block (first pass rate: 89% vs. 93%, p = .59), with a
shorter RF time (88 ± 40 s vs. 492 ± 269 s, p < .001) and similar
procedure (30 ± 4 vs. 34 ± 10 min, p = .5) time was observed.35
Besides PVI in the FAST and FURIOUS PVI study CTI block was
achieved by Qmode+ only in 13/13 patients. In one patient with a repeat
procedure, the CTI was checked and was found to be durable blocked.48
Similar findings have been evaluated in the FAST and FURIOUS CTI
study. Here complete CTI block using vHPSD ablation was achieved in all
15 patients. A median of 23 (20, 39) RF applications over a median RF
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6 | HEEGER ET AL.

F I G U R E 3 QDOT MICRO™ Catheter during cavotricuspid isthmus‐ablation in QMODE+. Three‐dimensional electroanatomic reconstruction
(CARTO 3, UNIVIEW module; Biosense Webster) of the right atrium in left anterior oblique and right anterior oblique during catheter ablation at
the cavotricuspid isthmus for the treatment of typical common type atrial flutter. Please note the white‐red tags created by radiofrequency
ablation utilizing the QDOT MICRO™ Catheter in the QMODE+ ablation mode. Source: Property of C. Heeger.

ablation time of 92 (78, 154) s were applied and no periprocedural
complications, no charring, and no steam pops were observed.49
The preliminary data show that vHPSD ablation might represent
an effective and safe strategy to achieve bidirectional CTI block for
the treatment of typical AFL. Please also see Supporting Information:
Video 2 for CTI‐block by vHPSD applications only.
the applicability of the microelectrodes for identifying potential
targets for catheter ablation. The combination of microelectrodes and
vHPSD ablation seems to be an interesting option for mapping and
ablation of atrial tachycardias (Figure 4).39 Please also see Supporting
Information: Video 3 for perimitral AT ablation by vHPSD only.

5 | AC C ESSO RY P ATHW AY ABLATI O N

4 | ABLA TION O F ATRIAL TACHYCARDIA
B Y T H E QD O T M I C R O™ C A T H E T E R
Although the QDOT MICRO™ Catheter was designed for atrial
procedures data on the treatment of atrial tachycardia is limited to
39
only one published case report.
Here a patient with perimitral atrial tachycardia with a critical
isthmus on the anterior wall was treated by the QDOT MICRO™
Catheter utilizing QMODE+ only. An ablation of an anterior line was
performed. After 10 vHPSD applications the atrial tachycardia
terminated and the anterior line was completed with a total of 29
applications with an extremely low RF time of 116 s. No periproce-
dural complications occurred. Interestingly the microelectrodes of the
QDOT MICRO™ Catheter showed sharp and fragmented potentials
at the area of the critical isthmus even though the standard
electrodes showed no visible signals. This observation demonstrated
Another case report has been recently published demonstrating the
safety and efficacy of vHPSD ablation of a left lateral accessory
pathway by a single 90 W/4 s RF application utilizing QDOT
MICRO™ Catheter. An immediate loss of pathway conduction was
reported. Afterward, three bonus applications of vHPSD have been
conducted. The 12‐lead ECG confirmed the absence of delta wave
even after 12 months of follow‐up.37
6 | INAPPROPRIATE SINUS
TAC HY C ARDI A
A case report of therapy‐refractory inappropriate sinus tachycardia has
been recently published. Ablation by a total of 42 vHPSD applications at
the sinus nodal area resulted in a significantly decreased in heart rate.
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HEEGER ET AL. | 7

F I G U R E 4 QDOT MICRO™ Catheter for ablation of atrial tachycardia by QMODE+. (A) Electroanatomic map of the left atrium utilizing
CARTO 3, V7 (Biosense Webster). Left side, left anterior oblique, LAO) view. A local activation time map with evidence of a peri‐mitral atrial
tachycardia, suggesting the critical isthmus at the anterior wall. Coppery area—zone of slow or no conduction (Coherent module; Biosense
Webster). (B) Voltage map with evidence of a large scar area on the anterior and posterior wall. The bipolar voltage reference interval was set
between 0.05 and 0.35 mV. (C) QDOT MICRO™ Catheter in QMODE+ and ablation at the anterior wall at the moment of atrial tachycardia
termination Left side, right anterior oblique (RAO) view; right side, LAO view. Note the ablation catheter in the anterior wall during delivery of a
very high‐power short‐duration application of 90 W/4 s. The contact force was 18 g and the distance from the previous application was 5.3 mm.
The “bullseye” in the left upper corner indicates the temperature of the ablation catheter tip. (D) Final lesion set up with an anterior line depicted
by red dots with white points. Source: Property of C. Heeger.

Since the sinus nodal area is located close to the phrenic nerve within the
thin‐walled RA vHPSD applications may result in more effective, broader,
and superficial lesion formation potentially avoiding collateral damage to
adjacent structures like the esophagus and the phrenic nerve.40
7 | ABLA TION O F PREMATURE
VENTRICULAR CONTRACTIONS UTILIZING
QMO DE+
Although vHPSD concepts have been evaluated for atrial procedures,
data for ablation within the ventricles is very limited. Only one case
report and one study for catheter ablation of PVC utilizing the QDOT
34,38
MICRO™ Catheter have been published in humans up to date.
In the initial case report a patient with frequent monomorphic PVC
originating from the right ventricular (RV) outflow tract (OT) (RVOT)
received 3D electroanatomic reconstruction of the right ventricle. The
earliest activation was detected within the anterolateral RVOT. At this
area the microelectrodes detected early fragmented potentials which
were not detectable on the standard bipolar electrode of the ablation
catheter. A single vHPSD application of 4 s was performed resulting in an
immediate loss of PVC. No periprocedural complications occurred and no
recurrent PVC was reported during long‐term follow‐up.38
After successful performing the above‐mentioned case a pilot study
for PVC treatment via QDOT MICRO™ Catheter was conducted. In the
prospective single‐center FAST and FURIOUS PVC study, we sought to
investigate the efficacy, safety, and clinical outcome of vHPSD ablation
for the treatment of idiopathic PVCs originating from the right and left
ventricular OTs (LVOTs). These data were compared to standard power‐
controlled ablation strategy using conventional contact‐force sensing
ablation catheters. In this study, 24 consecutive patients underwent PVC
ablation utilizing vHPSD ablation (study group) and were compared with
24 consecutive patients previously treated with power‐controlled
ablation (control group). Each group included 12 patients with PVCs
 15408167, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jce.16113 by Cochrane Chile, Wiley Online Library on [22/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
8 | HEEGER ET AL.

F I G U R E 5 QDOT MICRO™ Catheter for mapping and ablation of premature ventricular contractions (A) Electroanatomic map of the right
ventricle utilizing CARTO 3, V7 (Biosense Webster). Left side, left anterior oblique, LAO) view. Earliest activation of the frequent monomorphic
premature ventricular contraction (PVC, red pin within red area [Coherent module, Biosense Webster]) was found at the antero‐septal right
ventricular outflow tract (RVOT). Final lesion with three very high‐power short‐duration application of 90 W/4 s depicted by red dots with white
points. (B) Surface and intracardiac electrocardiograms with the QDOT MICRO™ Catheter at the location of earliest activation of the PVC within
RVOT. Please note the potentials on the microelectrodes (pointed out by black arrows). Abl d, distal electrodes on the map catheter; Abl p,
proximal electrodes on the map catheter; Abl u1–u2, Abl u2–u3, Abl u1–u3, microelectrodes. Speed 25 mm/s. Source: Property of C. Heeger.

originating from the RVOT and 12 patients with PVCs originating from
the LVOT. The acute endpoint of PVC elimination was achieved in all
patients. In this study, vHPSD was used as the first approach and was
switch to conventional QMODE after ineffectiveness. In 16/24 (67%)
patients (study group) the acute endpoint was achieved by using vHPSD
only (RVOT: 92%, LVOT: 42%). The earliest activation found on the
microelectrodes of the QDOT MICRO™ Catheter was significantly earlier
than on the standard bipolar electrodes. The median RF delivery time was
massively reduced utilizing vHPSD (p < .0001). No difference was
observed regarding procedure duration (p = .489), follow‐up (p = .712)
and severe adverse events (4%, study group, 8%, control group,
p = .551).34
Although the FAST and FURIOUS PVC study was a single center
nonrandomized study it demonstrated the feasibility and safety of
the QDOT MICRO™ Catheter for treatment of OVC originated from
the RVOT and LVOT. In the thin walled RVOT, the success rate of
vHPSD was 92%, while it was 42% for LVOT case. Therefore, it
seems to be reasonable to consider vHPSD (QMODE+) for PVC
originating from the RVOT (Figure 5) and conventional QMODE for
PVC originating from the LVOT.
PAF and PersAF and also other types of arrhythmias including typical
common type AFL, macroreentrant atrial tachycardia, supra-
ventricular tachycardia with accessory pathway as well as PVCs
was recently evaluated by preliminary case reports and studies (FAST
and FURIOUS studies). The authors experience includes also QDOT‐
based treatment of ventricular tachycardia in structural heart disease
(QMODE) as well as right and left AT and repeat ablation procedures
after initial successful PVI (QMODE+). However, those results are
preliminary. Although the results are promising further multicenter
evaluations are necessary to draw final conclusions.
A UT H O R C O N T R I B U TI O NS
Christian‐H. Heeger: Concept/design, data collection, data analysis
and interpretation, drafting article. Karl‐Heinz Kuck and Roland R.
Tilz: Critical revision and approval.
DATA AVAILABILITY STATEMENT
Non‐digital data supporting this study are curated at the study center
of the Department of Rhythmology, University Hospital Schleswig‐
Holstein, Germany.

ORC I D
8 | C ONC LUS I ON Christian‐H. Heeger http://orcid.org/0000-0002-9014-8097
Roland R. Tilz http://orcid.org/0000-0002-0122-7130
The QDOT MICRO™ Catheter offers vHPSD (90 W/4 s, QMODE+)
as well as conventional temperature‐controlled (QMODE, AI‐guided) TW I TT ER
ablation and showed safety and efficacy for PVI in several studies. Christian‐H. Heeger @ChristianHeeger
Beside those promising observations, its ability to treat patients with Roland R. Tilz @RolandTilz

HEEGER ET AL.
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SUPP ORTING INFO RM ATION
Additional supporting information can be found online in the
Supporting Information section at the end of this article.
How to cite this article: Heeger C‐H, Kuck K‐H, Tilz RR. Very
high‐power short‐duration catheter ablation for treatment of
cardiac arrhythmias: insights from the FAST and FURIOUS
study series. J Cardiovasc Electrophysiol. 2023;1‐10.
doi:10.1111/jce.16113