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Page 2 of 9 Rove et al. Vessel Plus 2022;6:55 https://dx.doi.org/10.20517/2574-1209.2021.133

Keywords: Postoperative atrial fibrillation, cardiac surgery, atrial fibrillation, administration management, quality of
health care, administrative efficiency

INTRODUCTION
Postoperative atrial fibrillation (POAF) is one of the most prevalent complications after cardiac surgery,
[1,2]
reported by the Society of Thoracic Surgeons (STS) as occurring in 20%-50% of cardiac surgical patients .
With over 300,000 cardiac operations performed annually in the United States, there are estimated to be
[3]
60,000 to 120,000 cardiac patients with new-onset POAF occurring per year . Once thought to be an
inconsequential postoperative clinical nuisance, there is mounting evidence of an association of any POAF
[4,5]
with worse short- and long-term outcomes ; thus, POAF represents a complication and phenotype in
need of serious attention. Despite the consistently high reported rates of the incidence of POAF,
astoundingly little is known about the “who”, “what”, “when”, “where”, “why” and “how” of cardiac surgical
[5]
POAF .
Across all cardiothoracic programs, POAF is arguably the largest “elephant in the room”. Unfortunately, the
published literature and professional society guidelines do not currently utilize a consistent definition of
postoperative atrial fibrillation, and nor is there a broadly followed consensus on how to prevent, treat or
[6]
manage POAF either in the hospital or after index cardiac surgical discharge . Furthermore, there is no
clear understanding of how POAF, regardless of rate- or rhythm-control strategies and resolution in the
perioperative period, is related to worse short- and long-term outcomes . Reviewing the POAF patient care
[2]
and management challenges posed herein, a strategic planning framework has been proposed to overcome
these POAF challenges.

Define POAF? the devil is in the details
Based on the literature review summarized by Pardo and colleagues, the atrial fibrillation (AF) and POAF
definitions used by clinical care providers are varied . These POAF definitions have specified the inclusion
[6]
of atrial fibrillation lasting more than 30 s, 60 s, 15 min, 30 min, 1 h, or the presence of any atrial fibrillation
at all. The published literature has specified the inclusion of atrial fibrillation requiring any treatment,
occurring within 7 days of surgery, or occurring within 10 days of surgery . Furthermore, conditions for
[3-8]
POAF detection have fluctuated between studies; these detection methods ranged from identifying new-
onset POAF using postoperative telemetry for 48 h, 72 h, until hospital discharge or no systematic detection
[3]
method was reported at all .
A case in point is the STS Adult Cardiac Surgery Database (ACSD) definition of POAF. As the largest
United States-based cardiothoracic surgery database, the STS ACSD monitors POAF as a postoperative
adverse outcome. The most recent STS ACSD definition of POAF is “atrial fibrillation/flutter (AF) after
operating room exit that: (1) lasts longer than 1 h; or (2) lasts less than 1 h but requires medical or
procedural intervention, excluding patients who were in atrial fibrillation at the start of surgery (entry into
operating room)” .
[9]

Several recent studies have advocated for a broader-based, more inclusive definition of POAF to better
capture adverse outcomes in patients excluded by the more restrictive POAF definitions. Two multicenter
studies of POAF in post-CABG patients compared the number of patients with an episode of atrial
fibrillation or flutter detected via continuous telemetry to the number of patients who were captured by the
more restrictive STS definition of AF lasting longer than 1 h or requiring treatment [10,11] . In Filardo’s recent
analysis of over 7000 isolated CABG patients with no prior history of AF, 2263 (31.8%) experienced POAF,