Abstract 4366862: Direct To Catheter Ablation and Pre-Ablation Rate Control Have Similar Outcomes in Persistent Atrial Fibrillation

Objective: To compare outcomes of direct-to-catheter ablation (DTCA) versus pre-ablation rate control using metoprolol or diltiazem in patients with persistent atrial fibrillation (PersAF). Methods: We evaluated 734 PersAF patients enrolled in the DECAAF II trial. Patients receiving metoprolol prior to ablation (n=260) were compared to those undergoing DTCA without beta-blockers (n=209); a similar comparison was performed for diltiazem (n=55) vs. DTCA without calcium channel blockers (CCBs) (n=639). The primary outcome was AF recurrence over 18 months, monitored via daily mobile ECG. Secondary outcomes included AF burden, SF-36 quality of life (QoL) scores, and changes in left atrial volume index. Kaplan-Meier analysis assessed recurrence. Multivariable Cox regression identified independent predictors of recurrence. Group differences in AF burden and QoL were assessed using Wilcoxon rank-sum and Student’s t-tests. Results: Across both comparisons of rate-control vs DTCA, rates of AF recurrence, AF burden, QoL, and atrial remodeling were statistically similar between groups (all p > 0.05). On multivariable analysis, neither metoprolol (HR 0.95; 95% CI 0.70–1.30; p=0.76) nor diltiazem (HR 1.4; 95% CI 0.9–2.1; p=0.10) independently predicted recurrence. Conclusion: In this DECAAF II subanalysis, both DTCA and pre-ablation rate control resulted in comparable outcomes in AF recurrence, burden, QoL, and atrial remodeling. These findings suggest that either strategy can be reasonable in the management of PersAF.