Pre-Ablation Rate Control Therapy and Direct-to-Catheter Ablation in Patients with Persistent Atrial Fibrillation: A DECAAF II Subanalysis

Background: For patients with persistent atrial fibrillation (PersAF), initial treatment strategies often involve rate or rhythm control before offering ablation. This study compared two approaches: (1) catheter ablation without prior medication (referred to as direct-to-catheter ablation, DTCA) and (2) catheter ablation after initial rate control with either diltiazem or metoprolol. Objective: This study included two independent comparative analyses of patients with persistent atrial fibrillation (PersAF) undergoing catheter ablation. Aimed at evaluating the potential impact of pre-ablation rate control medications including beta blockers and calcium channel blockers on post-ablation outcomes. Comparison 1: DTCA without prior beta-blocker use (n = 209) vs. metoprolol use prior to ablation (n = 260). Comparison 2: DTCA without prior calcium channel blocker use (n = 639) vs. diltiazem use prior to ablation (n = 55). Methods: Patients were followed for 18 months to evaluate primary outcome: recurrence of atrial fibrillation (AF) and secondary outcomes: Pre-ablation and Post-ablation left atrial percent fibrosis as seen on LGE MRI and Quality of life (QoL), measured with the SF-36 questionnaire. The Wilcoxon tests were conducted to compare the QoL and fibrosis among groups. Time to recurrence among the groups post ablation was assessed via Kaplan-Meier curves. Multivariable Cox models were developed to adjust for other confounders of AF recurrence. Results: In the beta-blocker analysis (n = 469), no significant difference in AF recurrence was observed between patients without prior beta-blocker use (DTCA group) and those treated with metoprolol (Kaplan-Meier, p > 0.05). Similarly, in the calcium channel blocker analysis (n = 694), no difference in recurrence was found between the DTCA group and those with prior diltiazem use (p > 0.05). Multivariable Cox models confirmed that neither metoprolol (p = 0.44) nor diltiazem (p = 0.34) independently predicted AF recurrence. Additionally, no significant differences were found in any fibrosis metrics or QoL between the groups in either comparison (all p > 0.05). Conclusion: Prior treatment with diltiazem or metoprolol before ablation of PersAF did not show additional benefits in reducing patient outcomes such as AF recurrence, fibrosis, or improving QoL.