Introduction:
Cardiac transplantation remains the gold standard treatment for end stage heart failure1, and despite the growing prevalence of advanced heart failure in the United States, donor heart supply critically limits rates of OHT2. This supply and demand mismatch is magnified by the fact that over 50% of offered donor hearts are not accepted for transplantation3. The reduced utilization of certain donor hearts is largely tied to the practice of rejecting organs that fall outside of strict donor selection criteria. This approach has been adopted from literature that suggests worse outcomes among recipients of certain donor types and concerns regarding regulatory reprimand for transplant centers with more pronounced mortality rates4. However, donor selection is more nuanced than the strict donor guidelines suggest.
In addition to published donor selection criteria, other features must be considered when selecting an appropriate donor. These include the clinical status and interactions of the donor-recipient pair, as well as the clinical volume and available infrastructure of the transplanting center. Although each of these components may impact the overall success of OHT with extended-criteria donor (ECD) hearts, higher transplant center volumes have been linked to improved survival over lower volume centers despite transplanting higher-risk recipients5–8. Furthermore, higher volume OHT centers may obtain a degree of their transplant volume by being more aggressive on the acceptance of donor hearts outside of the standard criteria. Considering the shortage of available donor hearts and that ECD hearts may be an option to expand the available donor pool, we investigated if the acceptance rates of ECD hearts varied among centers based on OHT volume and if the acceptance of these organs impacted outcomes.