"No Hearts Left Behind": A global proposal to rescue discarded donor hearts

Despite technological and logistical progress in heart transplantation, thousands of viable donor hearts are still discarded annually-particularly in the United States-while patients elsewhere continue to die waiting. This viewpoint proposes a global paradigm shift: enabling transatlantic exchange of unused donor hearts through advanced preservation technologies and reciprocal allocation frameworks. Using registry data from Eurotransplant and the United States, we highlight striking disparities in donor acceptance criteria, especially regarding older or donors previously considered less suitable. We argue that many of these organs, declined locally for non-biological reasons, could safely be transplanted in regions where differing practices and technologies allow their use. Advances in preservation-including temperature-controlled static storage, hypothermic oxygenated perfusion, and normothermic ex vivo systems-now permit safe transport over thousands of kilometers, challenging traditional constraints of time and geography. We outline the ethical, financial, and regulatory prerequisites for a transatlantic donor heart exchange system and propose early feasibility trials to initiate proof-of-concept sharing. Such a model would require transparency, international oversight, and an equitable "payback" mechanism to maintain trust and balance. Ultimately, we argue that a globally integrated approach to organ sharing-similar to international marrow registries-could transform access to transplantation, reduce waitlist mortality, and better honor the gift of donation. "No Hearts Left Behind" is more than a slogan: it is an ethical imperative supported by technological feasibility. The time has come to build the bridges-legal, logistical, and moral-that make global heart exchange a reality.