[Long-term anticoagulation after perioperative atrial fibrillation: a challenging issue]

Postoperative atrial fibrillation (POAF) after cardiac surgery is frequent, has a 4 to 5-fold risk of recurrences, and a pathophysiology mainly linked to triggers, including pericardiectomy. The risk of stroke is increased, while long-term anticoagulation therapy, based on available retrospective studies, is recommended by the European Society of Cardiology guidelines with class IIb and level of evidence B. On the other hand, POAF after non-cardiac surgery is less frequent, has a pathophysiology linked to the substrate rather than to triggers, and increases the risk of stroke and death. So far, long-term anticoagulation therapy (preferably with direct oral anticoagulants) has a class IIa recommendation with level of evidence B. Short-term anticoagulation after cardiac surgery, in the face of "provoked" atrial fibrillation, a well-known topic in the field of venous thromboembolism that has never found application in the field of atrial fibrillation, is often adopted in clinical practice although without evidence. The ongoing randomized trials will partially answer some of our questions, but, unfortunately, the management of POAF will remain a grey area and the indication for anticoagulation should be tailored.