A critical evaluation of donor heart offer acceptance in the United Kingdom.

Background: In the United Kingdom (UK), the adoption of donation after circulatory determination of death (DCD) has boosted transplantation rates by 20%. However, about 100 patients per year on the waitlist still do not receive a transplant due to low transplantation rates. Current reports review rates of utilisation after offer acceptance but fail to report the offer acceptance rate and the reasons for offer declines. We have therefore analysed the reasons why heart offers were declined over the past 16 years.

Methods: A retrospective analysis was conducted on the primary reasons for the decline of heart offers between 1^st January 2008 and 31^st December 2022. Reasons were obtained directly from the National Health Service Blood and Transplant Registry and categorised into five groups: 'donor-related', 'organ-related', 'recipient-related', 'logistical' and 'other'. These categories were then analysed.

Results: During this period, 2,673 heart offers were accepted for transplantation. Comparatively, 6,310 offers were declined, most commonly due to poor function (35.8%) and 'donor past medical history (PMH)' (20.4%), together accounting for 56% of all declined heart offers. The largest category was 'organ-related' reasons (47.6%), and the smallest group was 'logistical' reasons (1.0%). Recipient-related factors accounted for only 7.8% of declined offers.

Conclusions: Donor heart function and PMH are the most common reasons for declining heart offers, with non-clinical factors also contributing to offer declines. Greater acceptance rates can be achieved with greater logistical support for the UK heart transplantation networks and the implementation of more robust and objective assessment methods for offered hearts, including biomarkers and coronary angiography, particularly in DCD donation.