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Background Significant weight loss due to cardiac cachexia is an independent predictor of mortality in many heart failure (HF) clinical trials. The impact of significant weight loss while on the waitlist for heart transplant (HT) has yet to be studied with respect to post‐transplant survival. Methods Adult HT recipients from 2010 to 2021 were identified in the UNOS registry. Patients who experienced an absolute weight change from the time of listing to transplant were included and classified into two groups by percent weight loss from time of listing to time of transplant using a cut‐off of 10%. The primary endpoint was 1‐year survival following HT. Results 5951 patients were included in the analysis, of whom 763 (13%) experienced ≥10% weight loss from the time of listing to transplant. Weight loss ≥ 10% was associated with reduced 1‐year post‐transplant survival (86.9% vs. 91.0%, long‐rank p = .0003). Additionally, weight loss ≥ 10% was an independent predictor of 1‐year mortality in a multivariable model adjusting for significant risk factors (adjusted HR 1.23, 95% CI 1.04–1.46). In secondary analyses, weight loss ≥ 10% was associated with reduced 1‐year survival independent of hospitalized status at time of transplant as well as obesity status at listing (i.e., body mass index [BMI] < 30 kg/m2 and BMI ≥ 30 kg/m2). Conclusions Preoperative weight loss ≥ 10% is associated with reduced survival in patients listed for HT. Nutrition interventions prior to transplant may prove beneficial in this population.

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