eComment: Is it safe to stop anticoagulants after successful surgery for atrial fibrillation?

Gray et al. provide an important evidence-based synthesis of the complex literature on atrial fibrillation and the safety of stopping anticoagulants [1]. Any evidence-based article is limited by the quality of the evidence base analysed, and their analysis raises a number of points. Firstly, the definition of ‘successful’ needs to be made clear. Periods of paroxysmal atrial fibrillation are associated with an increased stroke rate and may need anticoagulant therapy as a prophylaxis [2]. Within the definition of successful, documentation of mechanical atrial activity and not just electrocardiogram evidence of sinus rhythm needs to be included, as an akinetic atrium has increased thomboembolic potential [3]. Secondly, the exact surgical technique of atrial fibrillation surgery needs to be stated, and concomitant surgical procedure(s) identified. The risk of a thromboembolic event will be lower in coronary artery bypass surgery patients than in mitral valve repair/replacement patients having concomitant atrial fibrillation surgery. The technique of left atrial exclusion, if indeed it was performed (sometimes omitted in elderly patients with frail tissues), may also affect thromboembolic risk. Thirdly, the patient's cardiovascular risk profile, via the CHADS2 score [4], is an important factor, as previously ecommented on by Koniari.