What is the clinical evidence from this study?

Study design: Cohort. Population: Long-standing persistent atrial fibrillation and severe mitral valve regurgitation (n=62). Intervention: Concomitant biatrial surgical ablation (modified Cox-maze IV). Primary outcome: Freedom from atrial fibrillation recurrence at 12 months (95% CI 58.8-81.8).

What does this research mean for the field?

Concomitant biatrial surgical atrial fibrillation ablation (modified Cox-maze IV) during mitral valve surgery is safe and effectively restores sinus rhythm at 12 months in approximately 70% of patients with long-standing persistent AF. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

May 27, 2026The Heart Surgery Forum0 citationsOpen Access

Concomitant Surgical Atrial Fibrillation Ablation (Modified Cox Maze IV) in Patients With Long-Standing Persistent Atrial Fibrillation Undergoing Mitral Valve Surgery: Experience From a UK Tertiary Center

DADincer AktuerkSt Bartholomew's Hospital TBThomas BarkerUniversity Hospital Coventry SRSikder M Zubair RahimUniversity Hospital Coventry

Key Result

Concomitant biatrial surgical ablation during mitral valve surgery in patients with long-standing persistent atrial fibrillation achieved a 69.4% freedom from atrial fibrillation recurrence at 12 months.

Study Design

Type

Cohort (n=62)

Multicenter

Structured PICO

Does concomitant biatrial surgical ablation during mitral valve surgery improve maintenance of sinus rhythm in patients with long-standing persistent AF and severe mitral regurgitation?

Population

62 patients with severe mitral regurgitation and long-standing persistent atrial fibrillation, mean age 70 ± 11 years, 51.6% female, mean CHA2DS2-VASc score 2.7 ± 1, treated at a UK tertiary center.

Intervention

Concomitant biatrial surgical ablation (biatrial modified Cox-maze IV with completion of the full lesion set using bipolar radiofrequency plus cryoablation) during mitral valve surgery.

Outcome

Sinus rhythm at 12 months documented on 24-hour Holter monitoringsurrogate

Concomitant biatrial surgical ablation during mitral valve surgery in patients with long-standing persistent AF achieves sinus rhythm in nearly 70% of patients at 12 months.

Limitations

Retrospective observational study from a single center
AF recurrences assessed via 24-hour Holter monitoring, which may have failed to detect episodes occurring outside the monitoring window
Low incidence of mortality and cerebrovascular events precluded meaningful multivariate analysis
No intraoperative mapping techniques used to confirm bidirectional block across ablation lines
Lacked precise data on the duration of persistent AF before cardiac surgery
No serial echocardiography data postoperatively to track changes in atrial contractility
Absence of a control arm

Abstract

Background:In patients with persistent atrial fibrillation (AF) and chronic severe mitral valve (MV) regurgitation, the success rate of cardioversion and long-term maintenance of sinus rhythm is poor. Concomitant AF ablation during MV surgery may improve outcomes. We report short- and medium-term results in patients undergoing concomitant AF ablation during MV surgery.Methods:This was a retrospective study of all consecutive patients with long-standing persistent AF who underwent MV surgery for severe MV regurgitation with concomitant biatrial surgical ablation (biatrial modified Cox-maze IV with completion of the full lesion set) between June 2015 and June 2018. Patients were followed at 3, 6, and 12 months postoperatively. Data from 24-hour Holter monitoring, baseline clinical parameters, complications, and AF recurrence were collected.Results:A total of 62 patients with severe mitral regurgitation and long-standing persistent AF underwent MV surgery with concomitant AF ablation. A standardized energy source (bipolar radiofrequency plus cryoablation) was used in all cases. The mean age was 70 ± 11 years; 32 (51.6%) were female, and the mean CHA2DS2-VASc score was 2.7 ± 1. At 12 months, sinus rhythm was documented in 43 (69.4%) patients on 24-hour Holter monitoring; 88.4% of those in sinus rhythm at follow-up demonstrated atrial contractility on echocardiography. Pacemaker implantation was required in 5 (8.1%) patients, and cerebrovascular events occurred in 3 (4.8%). Meanwhile, two patients (3.2%) required re-exploration for bleeding, but none needed re-intervention on the MV.Conclusions:Biatrial surgical AF ablation is a safe and effective adjunct in patients with long-standing persistent AF undergoing concomitant MV surgery and may be beneficial in the long term for maintaining a normal rhythm.

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