On day two of the 62nd Annual Meeting in New Orleans, co-lead authors Subhasis Chatterjee, MD, of Baylor College of Medicine, and Stefano Schena, MD, PhD, of the Medical College of Wisconsin, presented a summary of The Society of Thoracic Surgeons’ (STS) 2026 Clinical Practice Guidelines for the Prevention and Treatment of New-Onset Postoperative Atrial Fibrillation after Cardiac Surgery. Their presentation highlighted a comprehensive, surgery-specific framework designed to address new-onset postoperative atrial fibrillation (POAF), the most common complication following cardiac surgery.
To develop the guidelines, the STS Workforce on Evidence-Based Surgery convened a multidisciplinary panel to review contemporary evidence and generate practical, consensus-based recommendations focused specifically on POAF after cardiac surgery. Using a phase-based approach that spans the preoperative, intraoperative, and postoperative periods, the group synthesized data from randomized and observational studies and graded recommendations using standardized methods based on AATS/EACTS/ESTS/STS harmonization guidelines1.
The final document includes a total of 15 recommendations: eight on preventive strategies, three on intraoperative adjunctive procedures, and four on postoperative management. Key guidance includes two Class I recommendations addressing perioperative oral amiodarone and rhythm cardioversion for hemodynamically unstable POAF. Two Class IIa recommendations supporting posterior pericardiotomy and perioperative beta-blockers. Eight Class IIb recommendations reflected areas of uncertainty and limited data. Three Class III recommendations addressed therapies without demonstrated benefit.
A central theme of the guidelines is transparency around uncertainty and an emphasis on meaningful patient outcomes. “One of the goals of these guidelines was not to promote a single dominant therapy,” said Dr. Chatterjee, “but to provide a structured, phase-based approach that can reduce unwarranted practice variation while still allowing clinical judgment.” He emphasized that POAF should be viewed as a marker of perioperative vulnerability rather than an isolated rhythm disturbance, identifying patients at higher risk for complications and future atrial arrhythmias. This perspective supports targeted surveillance and follow-up rather than reflexive escalation of therapy.
The document also underscores that POAF is distinct from preexisting atrial fibrillation, with different mechanisms, natural history, and management implications. Core strategies include careful rhythm monitoring, early rate or rhythm control, and individualized anticoagulation decisions, while acknowledging persistent uncertainty around optimal anticoagulation timing and duration, arrhythmia burden, and the role of adjunctive surgical interventions.
Dr. Schena highlighted how the guideline development process itself reshaped the panel’s collective thinking. “When we started this project, all nine members had their own way to address atrial fibrillation occurring de novo after cardiac surgery,” he said. “The time spent discussing and reviewing helped us recalibrate our stance and recognize how limited the evidence truly is for many commonly used interventions.” He noted that while no single strategy eliminates POAF, its clinical impact can be significantly reduced through a combination of measures applied across the preoperative, intraoperative, and postoperative phases of care. He also emphasized that the long-term implications of POAF in patients without prior atrial fibrillation remain uncertain and must be weighed against individual patient risk factors.
Together, the guidelines provide a pragmatic framework that clinicians can operationalize across the surgical continuum. By emphasizing evidence-based practices, openly acknowledging uncertainty, and discouraging ineffective interventions, the document aims to support thoughtful clinical decision-making and improve outcomes for patients undergoing cardiac surgery.
1: Milojevic, M., Freemantle, N., Hayanga, J. A., Kelly, R. F., Myers, P. O., Petersen, R. H., ... & Bakaeen, F. G. (2025). Harmonizing guidelines and other clinical practice documents: A joint comprehensive methodology manual by the American Association for Thoracic Surgery (AATS), European Association for Cardio-Thoracic Surgery (EACTS), European Society of Thoracic Surgeons (ESTS), and Society of Thoracic Surgeons (STS). The Journal of thoracic and cardiovascular surgery, 169(1), 170-185.