Study Implications
This study demonstrates that there is wide variability in the acceptance of extended criteria donors among low-, mid-, and high-tier centers, yet the survival rates of recipients of ECD hearts are comparable regardless of center volume/aggressiveness. These findings suggest that widespread adoption of higher ECD utilization practices may increase donor heart availability in the United States without an adverse impact on posttransplant outcomes. When evaluating donors with extended-criteria features, donor age appears to be the only factor with potential impact on long-term outcomes.
The donor selection process is admittedly variable and subjective to a multitude of factors. Centers often reflect on their recent outcomes and adjust aggressiveness in donor acceptance accordingly. For example, a center with several recent posttransplant deaths may become more conservative in selecting donors. This sometimes can make associations difficult to ascertain between center aggressiveness, transplant volume, and outcomes, as it can become unclear which factor contributed to the other. Nonetheless, there is a general understanding amongst physicians involved in OHT that considerable variability exists not only between programs but amongst providers in the same institution. Donor characteristics that may lead one center or provider to decline an offer are considered negligible by others. Further complicating this issue is the status of the recipient. Recipients who are declining clinically may have less time to wait for a suitable donor, thus making the center more aggressive in their donor acceptance behavior. The current analysis cannot account for all of these potential influencing factors but does ultimately suggest that centers who have higher donor acceptance rates and greater ECD utilization do not seem to be adversely impacted with regards to posttransplant outcomes of their recipients. A better in-depth understanding of donor selection criteria and practice by these centers with potential education of less aggressive programs may yield higher rates of OHT nationally without a detrimental impact on outcomes.