The Weight of a New Heart: Bariatric Surgery after Heart Transplantation and its Clinical Impact

Introduction: Severe obesity (SO) after heart transplantation (HT) worsens long-term graft and patient outcomes. While bariatric surgery (BS) is effective for obesity, its safety and efficacy in heart transplant recipients (HTR) remains poorly defined. Methods: Using the TrinetX^® database, we conducted a retrospective cohort study of adult HTR with BMI ≥ 35 kg/m² between 2000 and 2023. Patients were divided into HTR with post-transplant BS (HTR/BS) and HTR without BS. Propensity score matching adjusted for age, sex, race, ethnicity, and BMI. Primary outcomes were 30-day post-BS complications. Secondary outcomes included mortality, heart failure, coronary artery disease, transplant complications and malignancy up to 5 years following BS. Results: In total, 375 patients (HTR/BS − 27; HTR − 348) were analyzed. HTR/BS had no 30-day mortality or major surgical complications. Heart failure rates were significantly lower in HTR/BS cohort at 1 and 3 years, but not at 5 years (13 vs. 24, OR 0.12, p = 0.003; 14 vs. 24, OR 0.14, p = 0.007; 18 vs. 24, OR 0.26, p = 0.1, respectively). At 5 years, transplant complications were significantly lower in HTR/BS vs. HTR (33% vs. 94%, OR 0.1, p = 0.001). Trends toward lower coronary disease were observed in HTR/BS but did not reach significance. Conclusion: Bariatric surgery is safe in selected HTR and may reduce long-term transplant complications. These findings support BS as a viable intervention for management of obesity post-HT, warranting further prospective validation.