Reasons for donor heart offer refusal in the United States: Results from 14,132 transplant clinician surveys in the Donor Heart Study

Background

Despite a shortage of donors for heart transplant (HT) in the United States, most potential donor hearts are discarded. We evaluated the reasons why and their temporal and geographic variation using a US-wide survey of HT clinicians.

Methods

The Donor Heart Study enrolled 4,333 adult potential heart donors in United States from 2015-2020. Separately by donor, each HT center that refused an offer for that donor was surveyed on their reason(s) for refusal. We measured the prevalence of 28 distinct donor-unrelated reasons for refusal and characterized their temporal and geographic variation.

Results

Of 14,132 surveys collected—each representing a single declined donor offer—donor-specific, recipient, and mismatch issues were cited in 49.3%, 24.3%, and 38.0%, respectively. Among surveys citing only donor-specific issues, the most common were age, coronary artery disease, left ventricular (LV) systolic dysfunction, and LV hypertrophy; other noncardiac issue(s) (e.g., drug use) were the sole reason in 20.6% of surveys citing only donor-specific issues. Donor age as a reason for offer refusal became increasingly prevalent over time, despite no accompanying change in the prevalence of older (50+ year-old) donors. Reasons for offer refusal varied widely by region, in a manner unexplained by regional differences in objective donor characteristics.

Conclusions

Our findings highlight the subjective nature of donor heart assessment. Further scrutiny of non–evidence based reasons for refusal could reduce discard of viable donor hearts.