Long-term outcomes of heart transplant recipients with a history of malignancy: a nationwide population-based cohort study

Background Heart transplant (HTx) is a recommended therapy for selected patients with advanced heart failure, but its application in patients with a pre-transplant history of malignancy (PTM) remains a clinical challenge. Using a recent, nationwide database, this study aimed to define the characteristics, cancer profiles, and time-dependent mortality risks in this growing population. Methods We conducted a retrospective cohort study using the Korean National Health Insurance Service (NHIS) database, identifying all adult HTx recipients from 2006 to 2022. We compared baseline characteristics, cancer incidence, and causes of death between recipients with and without PTM. Adjusted hazard ratios (aHR) were calculated using multivariable Cox proportional hazards models, with a landmark analysis performed at 1-year post-transplant to assess temporal risk patterns. Result Of 1,809 HTx recipients, 121 (6.7%) had PTM. While overall mortality across the entire follow-up did not differ significantly between groups (aHR = 1.27, 95% CI: 0.93-1.76), a landmark analysis revealed a temporal difference. Mortality risk within the first year post-HTx was similar (aHR = 0.90, 95% CI: 0.56-1.44). Beyond one year, however, the PTM group experienced significantly higher late-onset mortality (aHR = 1.96, 95% CI: 1.25-2.98). This increased late risk was driven by a substantially higher incidence of post-transplant cancer (aHR = 13.51, 95% CI: 9.51-19.17) and cancer-related death (aHR = 9.35, 95% CI: 4.82-18.14). Conclusion HTx recipients with PTM exhibit a distinct risk profile characterized by comparable early survival but significantly increased late-onset, cancer-driven mortality. These findings underscore the critical need for rigorous, long-term oncologic surveillance strategies as well as cardiovascular care tailored for this high-risk population.