Tailor‐Made Hybrid Pulsed‐Field and Radiofrequency Ablation Guided by ExTRa Mapping for Refractory Long‐Standing Persistent Atrial Fibrillation: First Experience With the Affera System Prism‐2

Background Pulmonary vein isolation (PVI) alone is frequently insufficient for persistent atrial fibrillation (AF). Although pulsed‐field ablation (PFA) ensures durable linear lesions, extensive transmural ablation risks iatrogenic atrial tachycardia. A tailored strategy combining PFA with titrated radiofrequency (RF) energy for mild substrate homogenization remains poorly defined. Case Summary A 77‐year‐old male with post‐stroke refractory long‐standing AF underwent a re‐do ablation. Biatrial substrate evaluation was performed using the ExTRa mapping system, enabled by the Affera system (Prism‐2) to visualize the nonmagnetic 20‐pole spiral catheter. Areas with a mean non‐passively activated ratio (%NP) ≥ 35% and low voltage (< 0.3 mV) were targeted. Following PFA‐led posterior wall isolation, mild homogenization was performed using the Sphere‐9 catheter with highly titrated RF energy (60%, 60°C, and 1‐s duration). Although AF did not terminate directly, the AF cycle length significantly prolonged, and sinus rhythm was restored via cardioversion. Post‐procedural mapping confirmed complete isolation without extensive dense scar formation at homogenization sites. The patient maintained sinus rhythm during follow‐up. Conclusion The hybrid PFA/RF system integrated with AI‐driven phase mapping enables a safe, non‐destructive, tailor‐made substrate modification strategy for refractory persistent AF.