Introduction:
Transesophageal echocardiography (TEE) is often used as an adjunct to transthoracic echocardiography (TTE) to identify sources of cardiac embolism after ischemic stroke and transient ischemic attack (TIA). Unlike TTE, TEE is invasive and may lead to aspiration. Few data exist on the risk of respiratory complications after TEE in patients with stroke and TIA.
Methods:
We performed a retrospective cohort study using inpatient and outpatient claims data between 2008 through 2016 from a 5% sample of Medicare beneficiaries. We included patients ≥65 years old and hospitalized with acute ischemic stroke or TIA, defined by validated ICD-9 and ICD-10 diagnosis codes. CPT codes and ICD procedure codes were used to ascertain whether TEE, endotracheal intubation, mechanical ventilation, intravenous thrombolysis, or mechanical thrombectomy were performed during the stroke/TIA hospitalization. The exposure was TEE, modeled as a time-varying covariate, and the outcome was acute respiratory failure, defined as endotracheal intubation and/or mechanical ventilation. Patients were censored at hospital discharge or 21 days from admission. Cox proportional hazards regression was used to adjust for age, race, Charlson comorbidities, diagnosis of stroke versus TIA, thrombolysis, and thrombectomy.
Results:
Of 103,072 patients included during the study period, 72,981 (70.8%) had a diagnosis of ischemic stroke and 30,091 (29.2%) had a diagnosis of TIA. A total of 5,096 (4.9%) underwent TEE. The cumulative rate of respiratory failure at 21 days was higher after TEE (13.1%; 95% CI, 8.8-19.2%) than in patients without TEE (9.7%; 95% CI, 8.7-10.9%). After adjustment for potential confounders, TEE was associated with an increased risk of intubation (HR, 1.6; 95% CI, 1.3-2.0). This association was present when we assessed TIA patients only (HR, 2.7; 95% CI, 1.1-6.8).
Conclusions:
In a large cohort of Medicare beneficiaries, we found that TEE was associated with an increased risk of respiratory failure in patients with ischemic stroke or TIA.
