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) suffering from persistent AF complicated by moderate-to-severe atrial functional mitral regurgitation (AFMR). Methods:A retrospective analysis was conducted on patients hospitalized with AFMR and AF between January 2019 and December 2024. Patients were stratified into a surgical group (n=91) and a medical therapy group (n=167) based on their treatment strategies. Propensity score matching (PSM) was applied at a 1:1 ratio to balance baseline characteristics, resulting in 91 matched pairs. The primary endpoint was all-cause mortality. Secondary endpoints included AF recurrence, recurrence of mitral regurgitation, and major adverse cardiac and cerebrovascular events (MACCE). Results:Baseline characteristics were balanced between the two groups after matching, with a mean age of approximately 73-75 years. The median follow-up duration was 3 years. The 5-year survival rates for the surgical and medical groups were 61.9% and 61.4%, respectively, showing no statistically significant difference in long-term survival (Log-Rank *P*=0.788). Compared with the medical group, the surgical group demonstrated a significantly reduced incidence of ischemic stroke (5.5% vs. 18.7%, *P*=0.012) and moderate-to-severe mitral regurgitation (28.6% vs. 100%, *P*<0.001). Although the incidence of cerebral hemorrhage was numerically lower in the surgical group (4.4% vs. 5.5%), the difference was not statistically significant (*P*=1.000). Regarding rhythm control, the AF recurrence rate in the surgical group was 78.0%; while this remains high, it was significantly lower than that of the medical group (*P*=0.002).Conclusion:For elderly patients with AFMR, surgical treatment did not significantly prolong overall survival but demonstrated significant advantages in correcting valvular pathology and preventing disabling ischemic stroke. Surgical therapy may serve as an effective strategy to improve prognosis in elderly patients with reasonable life expectancy, high stroke risk, and adequate surgical tolerance.