Percutaneous occlusion of the left atrial appendage is increasingly being used for stroke prevention in patients with non-valvular atrial fibrillation (AF) at high risk of complications from long term anticoagulation. We describe a case of left atrial appendage perforation after Watchman device deployment requiring emergency repair of the left atrium using sternotomy and cardiopulmonary bypass. Technical considerations for surgical decision making are discussed, in hemodynamically unstable patients as well as those at high risk for embolization.