Pre-Transplant Heavy Smoking Is Associated with Reduced Survival After Heart Transplantation Due to Infection and Malignancy

<b>Background</b>: Tobacco smoking is a known risk factor for adverse cardiovascular events. Many patients after heart transplantation (HTX) have a history of smoking, but the prognostic role of pre-transplant smoking remains uncertain. We thus investigated the effects of pre-transplant heavy smoking (≥20 pack-years) on outcomes after HTX. <b>Methods</b>: This observational retrospective single-centre study included 639 patients receiving HTX at Heidelberg Heart Center between 1989 and 2019. Patients were stratified by intensity of pre-transplant smoking (<20 pack-years or ≥20 pack-years). Analysis covered donor and recipient demographics, post-transplant medications, mortality including causes of death after HTX, and early post-transplant atrial fibrillation (AF) after HTX. <b>Results</b>: A total of 219 of the 639 HTX recipients (34.3%) had a pre-transplant history of heavy smoking (≥20 pack-years). These patients showed an increased 5-year post-transplant mortality (44.3% versus 28.6%, <i>p</i> < 0.001) and had a higher percentage of death due to infection/sepsis (21.5% versus 12.1%, <i>p</i> = 0.002) as well as due to malignancy (5.5% versus 1.7%, <i>p</i> = 0.007). Multivariate analysis demonstrated pre-transplant heavy smoking (≥20 pack-years) as an independent risk factor for five-year mortality after HTX (HR: 2.173, 95% CI: 1.601-2.950, <i>p</i> < 0.001). Analysis of secondary outcomes also showed a significantly higher rate of 30-day post-transplant AF (17.8% versus 11.7%, <i>p</i> = 0.032) in patients with a pre-transplant history of heavy smoking (≥20 pack-years). <b>Conclusions</b>: Pre-transplant heavy smoking is associated with early post-transplant AF, lung cancer, infection, and reduced survival after HTX.