Impact of pre-operative factors on post-operative atrial fibrillation outcomes after cardiac surgery: systematic review with meta-analysis, trial sequential analysis, and meta-regression

Objectives Post-operative atrial fibrillation (POAF) is the most common arrhythmia following cardiac surgery. We conducted a systematic review and meta-analysis to quantify the association between POAF and adverse outcomes.Methods We searched PubMed, Embase, CENTRAL, and Web of Science through December 2024. Studies comparing outcomes between POAF and non-POAF patients after cardiac surgery were included. Random-effects meta-analysis was performed. Trial sequential analysis, Bayesian analysis, subgroup analyses, and meta-regression were conducted. Evidence certainty was assessed using the GRADE framework.Results Fifty-four studies (623,962 patients) were included. POAF was associated with significantly increased risks of early mortality (RR 1.94; 95% CI 1.89–2.00; I2=0%), late mortality (RR 1.59; 95% CI 1.50–1.69; I2=30%), stroke (RR 1.39; 95% CI 1.34–1.44; I2=12%), and acute kidney injury (RR 1.53; 95% CI 1.49–1.57; I2=0%). Trial sequential analysis confirmed conclusive evidence for all outcomes. Bayesian posterior probability was 100% for all outcomes. GRADE certainty was moderate for early mortality, late mortality, and AKI; low for stroke. Meta-regression identified prior stroke prevalence and chronic kidney disease as significant effect modifiers.Conclusions POAF is associated with substantially increased risks of mortality, stroke, and acute kidney injury following cardiac surgery. These findings support evidence-based prevention strategies and comprehensive management of POAF.