We discuss the case of a 63-year-old African-American female with recent mechanical fall complicated by left femoral neck fracture requiring left hip hemiarthroplasty ∼2 weeks prior, who presented for evaluation of purulent drainage from her surgical site. She was altered and haemodynamically unstable on presentation, with heart rate ∼30 b.p.m. and blood pressure 80/60. She was cool to the touch, with crackles at bilateral lung bases and jugular venous distention to the angle of the mandible. An electrocardiogram (EKG) demonstrated complete heart block (CHB) with junctional escape rhythm (), and she was started on a continuous dopamine infusion and urgent temporary pacemaker was placed with improvement in her haemodynamics and mental status. She denied any lightheadedness or recurrent falls, but reported worsening fatigue over the week prior to presentation. She had no known history of coronary artery disease or structural heart defects, and EKG done prior to recent surgery demonstrated no evidence of conduction disease (). The differential diagnosis of CHB includes age-related degenerative disease, metabolic derangements (hypothyroidism, hypoglycaemia, hyperkalaemia), medication toxicity (beta-blockers, calcium channel blockers, digoxin), mechanical complications (following valvular interventions, endocarditis), or coronary ischaemia. In our patient, an acute insult from either ischaemia, metabolic derangements, or medication effects appeared more likely given her recently normal EKG. Initial laboratory data were significant for leukocytosis of 29.7 × 103/μL with neutrophilic predominance (85%), elevated lactic acid (6.2 mmol/L), and acute kidney injury (Cr 1.7 mg/dL from 0.7 mg/dL 3 weeks prior). High sensitivity troponin was mildly elevated at presentation (41 ng/L) but trended downwards thereafter. There were no other significant metabolic derangements, and thyroid-stimulating hormone was within normal limits. The patient denied taking additional doses of metoprolol prior to presentation. Blood cultures were drawn prior to initiation of empiric antibiotic therapy. EKG at presentation is shown in, which demonstrated CHB with junctional escape and intermittent premature ventricular complexes. Transthoracic echocardiogram (TTE) demonstrated normal left ventricular function with no significant valvular abnormalities or evidence of abscesses. Blood and wound cultures were drawn, and empiric antibiotic therapy was started with vancomycin and cefepime. A temporary transvenous pacemaker was placed from the right internal jugular approach prior to going to the operating room (OR) for wound debridement on Day 1 of her hospitalization. Initial blood cultures from presentation, prior to transvenous pacemaker insertion, returned positive for S. aureus and rifampin and gentamicin were added until sensitivities returned methicillin-resistant organisms. Further cultures remained positive, and she returned to the OR for complete removal of all hardware with antibiotic spacer placement. Given lack of clear reversible aetiology and normal TTE, she was planned for a leadless pacemaker placement to minimize device-related infective risk. Prior to this, a transoesophageal echocardiogram (TOE) was completed due to persistent bacteraemia despite apparent source control, which demonstrated a mobile echo-density measuring 1.6 × 0.9 cm on the atrial side of the septal leaflet of the TV. This appeared to be attached to the annulus and highly mobile with only mild tricuspid regurgitation (Videos 1 and 2). There was no clear evidence of abscess formation or other valvular pathology. With this finding, pacemaker implantation was deferred and she was continued on antibiotic therapy. She was noted to intermittently demonstrate sinus rhythm with first-degree atrio-ventricular block after 72 h of therapy, but the predominant rhythm remained CHB necessitating backup pacing. On hospital Day 5, she was able to sustain normal sinus rhythm with normal conduction pattern on EKG, and transvenous pacemaker was removed. She was evaluated by cardiothoracic surgery given persistent bacteraemia and underwent coronary angiogram as part of her pre-operative evaluation which demonstrated no obstructive coronary artery disease. Given her clinical improvement, resolution of sinus rhythm, and hesitancy about cardiac surgery, she was continued on 6 weeks of IV antibiotics with plan for repeat TOE and close cardiology and cardiothoracic surgery follow-up in the outpatient setting. Per documentation, she has been doing well, although she did not make her scheduled cardiology appointment or repeat TOE, which are now in the process of being rescheduled.