impaired systolic function and a calculated EF of 37%. There was no evidence of scarring or fibrosis on delayed enhancement images. He was unable to maintain sinus rhythm following DCCV and relapsed back into persistent AF. His CHA~2~DS~2~-VASc score was 1 (LV dysfunction) which does not strictly mandate anticoagulation; however, he made an informed decision to continue rivaroxaban.

On a follow-up TTE performed 3 months later, LV systolic function remained unchanged. His ramipril was increased and he was initiated on eplerenone. Left ventricular function gradually improved on optimal medical therapy and, at 8 months of follow-up, had returned to near-normal (EF 50--55%). He remained in AF and experienced a brief episode of left arm weakness and paraesthesia suggestive of a transient ischaemic attack (TIA) despite being compliant with anticoagulation. As his CHA~2~DS~2~-VASc score increased to 3 (TIA, LV dysfunction) he now had a clear indication for anticoagulation. Connective tissue disorders, syphilis, and Fabry disease screening were negative.

At 1-year follow-up, he was asymptomatic (New York Heart Association 1) but remained in AF and continued to participate in competitive rugby, whilst on oral anticoagulation despite counselling regarding the high bleeding risk. He was reluctant to terminate his professional rugby career prematurely and sought alternative stroke prevention strategies that obviated the need for continuous anticoagulation. He was referred to a Tertiary Cardiology Centre for further management of his AF and consideration of a left atrial appendage occlusion (LAAO) device. A 27 mm Watchman Flx (Boston Scientific, MA, USA) device was successfully deployed under general anaesthetic in the left atrial appendage with a good seal and no leaks ([*Figures 1*--*4*](#ytz242-F1){ref-type="fig"}, [Supplementary material](#sup1){ref-type="supplementary-material"}). He was discharged home on a 6-week course of aspirin and clopidogrel therapy with a follow-up transoesophageal echocardiogram to assess 