What is a reasonable inpatient imaging modality alternative to evaluate for infective endocarditis in a morbidly obese patient with poor acoustic windows on TTE and persistent bacteremia if TEE is not feasible or contraindicated?

This is an excellent question. Retrospectively gated cardiac CTA especially with the newer generations (Siemens Somatom force or Naetom alpha) are probably your best alternative. This would need careful planning and tube setting adjustments depending on the patient's body habitus as scattered and no...

PET combined with gated CTA would be good alternatives. CTA is an excellent modality for assessing for large vegetation (> 1 cm) when compared with TEE though it may miss smaller vegetations. It is also excellent at identifying aortic root abscesses. PET would be very beneficial if there is concern ...

When trans-esophageal echocardiogram cannot obtain acoustic windows, I agree with the CTA and PET as listed (newly added to the updated 2023 modified Duke criteria as imaging evidence - Fowler et al., PMID 37138445

Not included in the guidelines but another modality we utilize in ACHD is intracardiac...

FDG-PET would be a good option in this scenario. Morbid obesity generally not a contraindication to TEE but would likely require general anesthesia to be done safely.