What is a reasonable management strategy for severely symptomatic atrial fibrillation with persistent LAA thrombus in spite of compliance with several different anticoagulation agents?

Typically, with an appropriate anticoagulation regimen, it is not common to see a thrombus develop. However, there are sometimes cases, such as the scenario posed that LAA thrombus is noted despite compliance with anticoagulation. In my practice, if a thrombus develops despite compliance with a particular class of DOAC (e.g., apixaban or rivaroxaban), I would consider switching to a different category of DOAC, such as dabigatran, and repeating a TEE in 4-6 weeks. If the thrombus is still present...

As long as a candidate would likely need CT surgery to remove LAA/thrombus and MAZE. You could consider Penumbra, but that would be high risk, and you may also need brain protection. This type of patient would be best discussed and managed in a large hospital with HEART team discussion based on local expertise.