Background: Infectious endocarditis (IE) usually presents with variable imaging findings and is associated with high morbidity and mortality. Transesophageal echocardiography (TEE) is the gold standard method for diagnosing IE. However, the presence of prosthetic or calcified valves poses a diagnostic challenge for detection of IE and associated structural abnormalities. In recent years, there is growing literature supporting cardiac CT scan as an adjunct to TEE in such cases. Studies have also shown that cardiac CT has significantly high sensitivity for detecting peri-annular complications. Case A 79 year old male who underwent transcatheter aortic valve replacement (TAVR) for severe aortic stenosis one year ago presented with a one week history of worsening confusion and fatigue. His prior medical history includes non-ischemic cardiomyopathy with low ejection fraction (30-35%), deep vein thrombosis (DVT) and pulmonary embolism (PE). Labs were notable for leucocytosis 27,300/uL and thrombocytopenia with platelet count 20,000/uL. Patient was bacteremic with blood cultures growing oxacillin-resistant Staphylococcus epidermidis. TEE revealed a small vegetation concerning for infection versus thrombus. A CT abdomen revealed a 3.8 cm splenic infarct. Tagged WBC scan was thereafter considered to help delineate, but came back negative. Decision Making In setting of thrombocytopenia, repeat TEE was deemed unsafe. Alternatively, the patient underwent cardiac CTA which revealed hypoattenuating leaflet thickening (HALT) involving >75% of aortic valve leaflets (Figure 1) with no perivalvular leak or abscess thereby confirming IE. Conclusion Cardiac CT offers distinct advantages and has emerged as a great adjunct to echocardiography for the workup of IE, especially in patients who have contraindications to TEE or with prosthetic valves where echocardiography is sub-optimal. The report further elucidates the role of cardiac CT as an imaging adjunct for IE.

Introduction: Contemporary data on the outcomes after Transcatheter Aortic Valve Implantation (TAVI) in patients with a baseline right bundle branch block (RBBB) remains limited. Methods: We analyzed National Inpatient Sample (NIS) data from the year 2011 to 2018. Results: Of the patients who underwent TAVI, 3472 (1.6%) had baseline right bundle branch block and 212467 (98.4%) did not. The patients who had baseline RBBB were older at 83 years [Interquartile range (IQR), 77-87] vs 82 [75-87]) and had higher male gender representation (66.7 % vs 52.2%) (p<0.01 for all). Rates of permanent pacemaker implantation was significantly higher in the RBBB group compared to no RBBB group (30.5% vs 10.80%, p<0.01). Median Cost of care ($53206 vs $48429) and length of stay (5 vs 4 days) were considerably higher for patients with RBBB when compared to the comparison group (p<0.01 for all). Logistic regression analysis showed that age greater 75 [OR] 1.26 [95% CI 1.21-1.31], male sex [OR] 1.12 [95% CI 1.09-1.15] , atrial fibrillation [OR] 1.29 [95% CI 1.07-1.57], coronary artery disease [OR] 1.07 [95% CI 1.04-1.11] diabetes [OR] 1.07 [95% CI 1.02-1.12], hypertension [OR] 1.10 [95% CI 1.05-1.15] obesity [OR] 1.10 [95% CI 1.05- 1.1.16] and renal failure (OR, 1.12 [CI, 1.09-1.15] were significant predictors of PPM implantation post TAVI in patients with a RBBB at baseline. Conclusions: In conclusion we report that RBBB is associated with increased pacemaker implantation after TAVI. Factors like age greater than 75, male gender, coronary artery disease, diabetes, hypertension, obesity, and renal failure are associated with higher incidence of PPM implantation.

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