Cardiac Surgery and Postoperative Atrial Fibrillation: The Role of Cancer

Background: Postoperative atrial fibrillation (POAF) is the most frequent arrhythmic complication following cardiac surgery, affecting nearly 20-30% of patients. While conventional risk factors such as age, hypertension, and atrial enlargement are well known, emerging evidence suggests that cancer itself constitutes a significant, yet underrecognized, contributor to POAF risk. Objective: This review aims to systematically examine the association of cancer with POAF, explore underlying pathophysiological mechanisms, and discuss clinical implications for risk stratification and management in cardiac surgical patients with concurrent or historical malignancies. Methods: A comprehensive review of recent literature was conducted using PubMed and Scopus databases. Studies focusing on the epidemiology, mechanisms, and clinical management of POAF in patients with cancer were evaluated. AI-assisted tools (OpenAI's ChatGPT) were used for formatting the graphical abstract. Results: Lung, breast, gastrointestinal, hematologic, and prostate cancers demonstrate the strongest association with POAF. The arrhythmogenic mechanisms include systemic inflammation, hypercoagulability, direct cardiotoxicity from cancer therapies, autonomic dysregulation, and paraneoplastic syndromes. Integration of oncologic variables into perioperative cardiovascular care is essential for precision risk assessment and outcome optimization. In a recent prospective cardiac surgery cohort, active or historical cancer independently conferred ~4-fold higher odds of POAF (adjusted OR: 3.85, 95% CI: 1.54-9.66), with cancer present in 15% of POAF cases versus 4% of non-POAF patients. Conclusions: Cancer represents a pivotal and multifactorial risk factor for POAF after cardiac surgery. Recognizing its role calls for a multidisciplinary approach that aligns oncologic and cardiovascular care to mitigate arrhythmic risk and improve surgical outcomes.