Intra-operative discovery of left atrial appendage (LAA) thrombus on transesophageal echocardiography (TEE) poses a dilemma. While LAA thrombi are classically managed medically, leaving a thrombus in a patient undoubtedly increases the risk for life-altering stroke. Additionally, medical management with anticoagulation increases risk for hemorrhagic complications. Direct appendage incision and thrombus extraction under TEE guidance followed by appendage clip closure provides a simple, elegant solution to this complex problem.