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.

Background and aims: Atrial fibrillation (AF) frequently accompanies rheumatic mitral valve disease (MVD) and adversely affects postoperative outcomes. Radiofrequency ablation (RFA) and cryoablation are commonly used during mitral valve surgery, but their comparative impact on atrial remodeling in this population remains uncertain. Methods: This retrospective cohort included 100 patients with rheumatic MVD and persistent AF who underwent mitral valve surgery with concomitant cryoablation ( n = 50) or RFA ( n = 50) between June 2020 and June 2024 at centers in the Almaty region, Kazakhstan. Clinical and echocardiographic parameters were assessed preoperatively, within 48 h postoperatively, and at 6 ± 2 months. Results: Cryoablation was associated with greater left atrial (LA) volume reduction immediately and at follow-up (both p < 0.001). Multiple linear regression identified ablation modality as the only independent predictor of LA volume reduction ( β = 27.9 mL, p < 0.0001), whereas duration of rheumatic disease, BMI, EuroSCORE II, and AF recurrence were not significant. At follow-up, the reduction in right atrial short-axis diameter was smaller after cryoablation ( p = 0.049), and stroke volume declined less compared with RFA (–1.2 ± 17.3 mL vs. −7.3 ± 15.8 mL; p = 0.006). Cardiopulmonary bypass time, aortic cross-clamp time, and postoperative symptom improvement were comparable between groups. Freedom from AF during follow-up was also similar (log-rank p = 0.52). Conclusions: In patients with persistent AF and rheumatic MVD undergoing mitral valve surgery, cryoablation was associated with more pronounced early atrial reverse remodeling and better preservation of stroke volume compared with RFA, without differences in operative efficiency or short-term safety. These findings should be considered hypothesis-generating, and prospective randomized studies with standardized lesion sets are required to confirm modality-specific effects.