Aggressive Donor Heart Acceptance and Early Outcomes After Heart Transplantation

Limited donor organ availability and variable acceptance practices continue to constrain heart transplantation (HT) access in the United States. We examined whether center-level donor offer acceptance (DOA) aggressiveness, measured by the OPTN-introduced DOA ratio was associated with early post-transplant outcomes for 5,393 adult HTs across 106 U.S. transplant centers (January 2024-June 2025). Centers were stratified into restrictive (Q1), intermediate (Q2-Q3), and aggressive (Q4) DOA quartiles. Aggressive-DOA centers utilized older donors, more DCD hearts, and accepted organs with greater travel distances. Despite this, 1-year recipient survival did not differ significantly across DOA groups in either Kaplan-Meier (p=0.253) or adjusted Cox proportional hazards analyses (p=0.277). Rates of severe primary graft dysfunction requiring ECMO, post-transplant stroke, and hemodialysis were also comparable. Aggressive-DOA was moderately correlated with higher center volume. Notably, Aggressive donor heart acceptance was not associated with worse 1-year survival, supporting broader donor utilization to expand HT access without compromising early recipient outcomes.