Effect of sodium glucose cotransporter 2 inhibition immediately prior to heart transplantation

Sodium glucose cotransporter 2 inhibitors (SGLT2i) are an established treatment for heart failure and type 2 diabetes. Guidelines suggest withholding SGLT2i preoperatively due to the risk of ketoacidosis. Orthotopic heart transplantation (OHT) occurs without sufficient notice to cease SGLT2i treatment before surgery. In a retrospective analysis of 163 OHT recipients (40 exposed to SGLT2i, 123 not exposed), we show no increase in rates of mild, moderate, or severe acidosis postoperatively. No cases of ketoacidosis occurred, likely due to the fact that 97% of patients received insulin infusions postoperatively for transient postoperative hyperglycemia. Patients exposed to SGLT2i had shorter length of stay in the intensive care unit and improved adjusted survival overall. These findings support the safety of SGLT2i use up to the time of OHT with routine use of a postoperative insulin infusion.