Stroke remains a major complication of atrial fibrillation and third leading cause of death in Western Countries.  While Coumadin and novel oral anticoagulants have been efficient in reducing the stoke risk in patients with atrial fibrillation; there is a subset of patients who are not candidates for anticoagulation.  The management of these patients is clinical challenge. We describe a patient with history of permanent atrial fibrillation with contra-indication to anticoagulation presenting with and left atrial thrombus. She was treated with novel generation of epicardial left atrial appendage exclusion device.