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.