Predictors of intraoperative donor heart turndown after initial acceptance for transplantation

Because of the low use of potential heart donors, it is important to maximize transplantation and minimize discard of accepted offers. We analyzed national registry data to investigate risk factors for intraoperative turndown of donor hearts that were initially accepted for transplantation.

All adult deceased donors who donated ≥1 organs during the period from January 2005 to March 2023 in the United Network for Organ Sharing database and received an acceptance or provisional acceptance by a heart team were categorized by heart allograft use versus intraoperative turndown (ITD). We investigated risk factors for ITD using multivariable logistic regression adjusted for covariates with P < .2 on univariate analysis.

Of 48,240 potential adult donors who received an acceptance from a heart transplant center, 43,401 (90.0%) of donors resulted in heart use, 1262 (2.6%) resulted in heart ITD, and 3577 (7.4%) resulted in heart nonuse for other reasons. ITD increased from 0.75% in 2005 to 2.2% in 2023 as a proportion of potential heart recoveries annually (P-trend = .02). On adjusted analysis, the strongest independent risk factor for ITD was donation after circulatory death (adjusted odds ratio, 2.60; 95% confidence interval, 1.86-3.62; P < .001), followed by older donor age (age ≥50 [vs <30] years [adjusted odds ratio, 2.02; 95% confidence interval, 1.59-2.56], P < .001). Additional independent risk factors included left ventricular ejection fraction ≤50%, >10 transfusions during terminal hospitalization, Hispanic and Other (vs White) race/ethnicity, death attributable to stroke, and hypertension.

We identified several factors associated with intraoperative turndown that can inform anticipatory intraoperative evaluation and team coordination while preserving access to donor hearts.