Concomitant surgical ablation for atrial fibrillation in mitral valve surgery: a systematic review of clinical outcomes and surgical strategies

Background Atrial fibrillation frequently coexists with mitral valve disease and is associated with adverse clinical outcomes. Concomitant surgical ablation has emerged as an effective strategy to restore sinus rhythm during mitral valve surgery. Methods A systematic review was conducted according to PRISMA guidelines. Electronic databases were searched for studies published between January 1991 and January 2026. Eligible studies included adult patients undergoing mitral valve surgery with concomitant surgical ablation. Due to heterogeneity, a qualitative synthesis was performed. Results A total of 25 studies were included. Early evidence established the Cox-Maze III procedure as an effective approach with high rates of sinus rhythm restoration. Contemporary data demonstrate that the Cox-Maze IV procedure provides comparable efficacy with reduced technical complexity. Long-term follow-up showed sustained sinus rhythm in a substantial proportion of patients, with possible reductions in thromboembolic events and possible survival benefit reported in some observational studies. However, interpretation of these findings is limited by clinical and methodological heterogeneity. However, an increased risk of permanent pacemaker implantation remains a consistent finding. Procedural success is influenced by lesion set configuration, completeness of ablation, and surgical approach. Conclusions Concomitant surgical ablation during mitral valve surgery is consistently associated with better rhythm outcomes, while evidence for harder clinical endpoints, including stroke and survival, remains less certain. Individualized surgical approaches remain essential to balance rhythm efficacy, procedural complexity, and the risk of permanent pacemaker implantation.