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Life sciences · Journal article
Journal of Arrhythmia · November 4, 2026
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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.