Heart Transplant Outcomes in Chemotherapy-Induced vs. Non-Ischemic-Dilated Cardiomyopathy: Pediatric and Adult Recipients in the Ventricular Assist Device Era.

BACKGROUND

Chemotherapy-induced dilated cardiomyopathy (CIDCM) has become an increasingly recognized indication for heart transplantation (HT) among cancer survivors with end-stage heart failure (HF). Advances in cardio-oncology practices, mechanical circulatory support, and refined immunosuppression strategies have improved outcomes; however, comparative data with non-ischemic dilated cardiomyopathy (NIDCM) in the modern ventricular assist device (VAD) era remain limited. Therefore, this study primarily aimed to compare post-transplant outcomes between CIDCM and NIDCM within pediatric and adult cohorts in the VAD era.

METHODS

Data from the United Network for Organ Sharing (UNOS) registry were used to retrospectively analyze first-time orthotopic HT recipients between January 2010 and March 2023, with follow-up through March 2024. CIDCM was defined using the UNOS diagnosis codes "dilated myopathy-adriamycin" or "dilated myopathy-cancer", whereas NIDCM included idiopathic, familial, myocarditis-related, and other specific DCM subtypes. Primary outcomes were post-HT survival, treated allograft rejection, and new or recurrent malignancy.

RESULTS

Among 28,813 recipients, 527 had CIDCM (52 pediatric, 475 adults). Pediatric survival was comparable between groups (1-, 5-, and 10-year survival: 0.92, 0.86, 0.76 vs. 0.95, 0.82, 0.68; p = 0.951). Adults with CIDCM showed superior survival (0.92, 0.82, and 0.68 vs. 0.91, 0.79, and 0.59; p = 0.018; hazard ratio (HR) 0.78 (0.64-0.96)) and lower rejection rates (0.03 vs. 0.04 events/person-year; p = 0.0027), with similar incidence of post-HT malignancy. Older age, female sex, and minority race were associated with reduced survival. In pediatric recipients, age >10 years and Ebstein Bar Virus (EBV) seronegativity were associated with post-HT malignancy; in adults, age ≥50 years was predictive.

CONCLUSIONS

HT in CIDCM achieves durable survival and safety comparable to NIDCM. These results support expanding HT eligibility and multidisciplinary evaluation for cancer survivors with advanced HF in the contemporary era.