How do you determine which atrial fibrillation patients with a high thromboembolic risk and a contraindication for oral anticoagulation should undergo left atrial appendage occlusion?

If the contraindication is absolute, all high risk patients need to be informed about the availability of LAAO devices. If the patient cannot take an anticoagulant or antiplatelet for a short period after implant, an epicardial approach could be considered.

(One of the) the main issues with absolute CI to anticoagulation is any endocardial exclusion device will require antiplatelet which has similar bleeding to apixaban in some trials. In true CI patients, I would favor sending for clipping.