Cardiovascular disease is a leading cause of morbidity and mortality in the United States and abroad, manifesting as shortness of breath, exercise intolerance, palpitations, and chest pain. Common cardiovascular diseases include coronary artery disease (5.6% of the U.S. population), atrial fibrillation (0.95% of the U.S. population), and diseases affecting the heart valves (2.5% of the U.S. population).1-3 While the majority of cases are treated medically, more advanced or severe cases are treated surgically or endovascularly, warranting an open discussion between the provider and the patient to decide the most appropriate treatment modality given the specific characteristics and preferences of the procedure and the patient. The Cox-MAZE IV is a surgical procedure to treat atrial fibrillation that utilizes mainly applied radiofrequency and cryothermal energy (as opposed to the “cut-and-sew” techniques in prior iterations) to treat atrial fibrillation.4-7 Coronary Artery Bypass Grafting (CABG) allows for the bypass of stenotic or occluded coronary arteries through the use of arterial or venous conduits. Mitral valve repair, or replacement, can be used for correcting mitral valve disease. Though the aforementioned procedures address different pathologies of the heart, some or all may be necessary at the same time due to concomitant disease. The Cox-MAZE IV combined with CABG and Mitral Valve Replacement is a singular surgical procedure that is carefully planned and executed to address arrhythmic, coronary, and valvular disease while minimizing time on cardiopulmonary bypass with an arrested heart.