Sodium-glucose cotransporter 2 inhibitor use and outcomes after surgical aortic valve replacement.

Abstract

Sodium-glucose cotransporter 2 inhibitors have demonstrated mortality and heart failure hospitalization benefits across cardiovascular populations. However, their impact on patients with severe aortic stenosis undergoing surgical aortic valve replacement, with or without concomitant coronary artery bypass grafting, remains unclear. This study evaluated clinical outcomes associated with sodium-glucose cotransporter 2 inhibitor use in a real-world surgical aortic valve replacement population. Patients who underwent surgical aortic valve replacement or combined surgical aortic valve replacement and coronary artery bypass grafting between 2014 and 2025 were reviewed. The inclusion criteria were consistent with contemporary trials including severe aortic valve replacement with left ventricular ejection fraction 40% or less, estimated glomerular filtration rate 25 to 75 mL/min/1.73 m², or type 2 diabetes mellitus. Propensity score matching was used to adjust for baseline differences. The primary outcome was all-cause mortality. Secondary outcomes included stroke, heart failure hospitalization, atrial fibrillation admission, and all-cause rehospitalization. A total of 2930 patients (age 76 [69-83] years, 40.3% female) were included, of whom 85 (2.9%) received sodium-glucose cotransporter 2 inhibitor therapy. In the overall cohort, sodium-glucose cotransporter 2 inhibitor use was associated with significantly lower 5-year all-cause mortality compared with nonuse (13.6% vs 33.5%, log-rank P = .022). After matching, mortality remained lower among sodium-glucose cotransporter 2 inhibitor users (13.8% vs 25.8%, P = .012), with reduced stroke incidence (2.0% vs 19.3%; P = .046) and no significant differences in atrial fibrillation or rehospitalization. In patients undergoing surgical aortic valve replacement, perioperative sodium-glucose cotransporter 2 inhibitor therapy was associated with improved 5-year survival and reduced stroke risk. These observational findings are hypothesis generating and support further investigation of sodium-glucose cotransporter 2 inhibitors in prospective, randomized studies in the surgical valve population.