Atrial fibrillation after surgical aortic valve replacement: the dark side of safe procedure

Atrial fibrillation (AF) is the most common arrhythmia that occurs after cardiac surgery. Postoperative atrial fibrillation (POAF) has an incidence of 20–40%, depending on the type of procedure, with higher rates after valvular surgery (30–50%). Postoperative AF is more common in older patients, patients with concomitant valvular heart disease, hypertension, heart dysfunction and renal failure. The cause of postoperative AF is multifactorial and related to both the underlying atrial substrate and the acute inflammation, oxidative stress and sympathetic output associated with cardiac surgery. Current European Society of Cardiology and European Association for Cardio-thoracic Surgery joint guidelines state that oral anticoagulation (OAC) therapy may be considered in patients with POAF (class IIb, lever of evidence B), after taking stroke risk and bleeding risk into consideration. This recommendation is based on a few retrospective studies involving cardiac surgery patients, while the remaining evidence come from non-surgical AF patients. No specific recommendations for OAC in surgical aortic valve replacement (SAVR) patients with POAF have been published.