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Introduction Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, and results in significant morbidity and mortality. The Cox‐Maze IV procedure (CMP‐IV) has been shown to have excellent efficacy in returning patients to sinus rhythm, but there have been few reports of late follow‐up in sizable cohorts of patients with longstanding persistent AF, the most difficult type of AF to treat. Methods and Results Between May 2003 and March 2020, 174 consecutive patients underwent a stand‐alone CMP‐IV for longstanding persistent AF. Rhythm outcome was assessed postoperatively for up to 10 years, primarily via prolonged monitoring (Holter monitor, pacemaker interrogation, or implantable loop recorder). Fine‐Gray regression was used to investigate factors associated with atrial tachyarrhythmia (ATA) recurrence, with death as a competing risk. Median duration of preoperative AF was 7.8 years (interquartile range: 4.0–12.0 years), with 71% (124/174) having failed at least one prior catheter‐based ablation. There were no 30‐day mortalities. Freedom from ATAs was 94% (120/128), 83% (53/64), and 88% (35/40) at 1, 5, and 7 years, respectively. On regression analysis, preoperative AF duration and early postoperative ATAs were associated with late ATAs recurrence. Conclusion Despite the majority of patients having a long‐duration of preoperative AF and having failed at least one catheter‐based ablation, the stand‐alone CMP‐IV had excellent late efficacy in patients with longstanding persistent AF, with low morbidity and no mortality. We recommend consideration of stand‐alone CMP‐IV for patients with longstanding persistent AF who have failed or are poor candidates for catheter ablation.

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