Objective：To evaluate the clinical efficacy and long-term prognosis of surgical mitral valve repair combined with atrial fibrillation（AF）ablation versus standardized medical therapy in elderly patients（ ≥70 years）with persistent AF complicated by moderate - to - severe atrial functional mitral regurgitation（AFMR）. Methods：This retrospective cohort study included consecutive patients aged ≥70 years with AFMR and persistent AF，admitted to the First Affiliated Hospital of Nanjing Medical University or Yili Prefecture Friendship Hospital between January 2019 and December 2024. Patients were divided into two groups according to treatment strategy：the surgical group（mitral valve repair+ablation+left atrial appendage closure）and the medical group（standardized pharmacotherapy）. Propensity score matching（PSM）was performed at a 1∶1 ratio to balance baseline characteristics，resulting in 91 pairs of patients. The primary endpoint was all - cause mortality；secondary endpoints included ischemic stroke，AF recurrence，and recurrence of mitral regurgitation. Results：The median follow-up for the 91 matched pairs was 41.5（26.4，47.0）months. A total of 46 deaths occurred during follow-up. The 5-year survival rates in the surgical and medical groups were 61.9% and 61.4%，respectively，with no significant difference in overall survival distributions（Log -Rank P=0.788）. Compared with the medical group，the surgical group had a significantly lower incidence of ischemic stroke（5.5% vs. 18.7%，P=0.012）and moderate -to -severe mitral regurgitation （28.6% vs. 100.0%，P ＜ 0.001）. The AF recurrence rate in the surgical group was significantly lower than that in the medical group （78.0% vs. 100.0% ，P=0.002）. No significant differences were found in the rates of intracranial hemorrhage or heart failure hospitalization between the two groups（all P ＞ 0.05）. Conclusion：In elderly patients with AFMR and AF，surgical intervention does not significantly prolong overall survival but offers substantial advantages in correcting valvular lesions and preventing disabling strokes. Clinical decisions should be individualized，based on an integrated assessment of physiological reserve and stroke risk.