COR LOE Recommendations In patients with VHD and AF for whom surgical intervention is planned, the potential symptomatic benefits and additional procedural risks of adjunctive arrhythmia surgery at the time of cardiac valvular surgery should be discussed with the patient.1 11 For symptomatic patients with paroxysmal or persistent AF who are undergoing valvular surgery, surgical pulmonary vein isolation or a maze procedure can be beneficial to reduce symptoms and prevent recurrent For patients with AF or atrial flutter who are undergoing valve surgery, LA appendage ligation/excision is reasonable to reduce the risk of thromboembolic events.16 19 In patients undergoing LA surgical ablation of atrial arrhythmias and/or LA appendage ligation/excision, anticoagulation therapy is reasonable for at least 3 months after the 3: Harm B-NR For patients without atrial arrhythmias who are undergoing valvular surgery, LA appendage occlusion/exclusion/amputation is potentially Synopsis For patients undergoing valve surgery with symptom- atic AF or atrial flutter, concomitant maze procedure with or without atrial appendage occlusion/exclusion/ amputation is a proven treatment for the atrial arrhyth- mia but requires postoperative anticoagulation for at least 3 months after the procedure (Figure 20). Recommendation-Specific Supportive Text 1. Surgical ablations, including pulmonary vein isola- tion and atrial maze at the time of valvular surgery and other open cardiac operations, have been dem- onstrated in multiple studies to reduce the recur- rence of AF.5 11 Various approaches to pulmonary vein isolation and modified left atrial, right atrial, and bi-atrial maze procedures entail longer proce- dure times, with higher risks of operative complica- tions and permanent pacemaker implantation.1 4 These adverse outcomes, coupled with the lack of large randomized trial data confirming mortality and stroke benefit, should be examined with the patient. 2. 