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Heart transplant centers that tend to wait for the perfect donor may be doing their patients a disservice, as registry data showed waitlist mortality was particularly high among hospitals with lower donor acceptance rates.

The overall acceptance rate for the first-rank offer of a donor heart was 32.0% among transplant centers, with some accepting as few as 12.3% of offers and others as many as 61.5%, reported Ashley Choi, BA, a medical student at Duke University School of Medicine in Durham, North Carolina, and colleagues in .

Hospitals accepting more donor hearts had lower 1-year mortality among their waitlisted patients: for every 10% increase in adjusted acceptance rate, mortality risk fell by 27% (HR 0.73, 95% CI 0.67-0.80).

What's more, between hearts accepted at the first-rank compared with lower-rank positions, there was no statistically significant difference in 5-year adjusted posttransplant patient survival (adjusted HR 1.02, 95% CI 0.94-1.11) and graft failure (HR 0.95, 95% CI 0.83-1.09).

"Because each center must elect to accept or decline an allograft before a candidate may proceed to transplant, center-level acceptance patterns represent a modifiable behavior that may substantially affect equitable organ allocation and overall mortality among candidates who are on the waitlist," the authors said.

Candidate, donor, and geographic factors are currently considered when deciding whether a donor heart is accepted.

"Although these factors have been shown to be associated with posttransplant survival, it is rare that the perfect donor is available, and every center has developed its own guideline to balance these factors. As such, the lack of standardization of practice and acceptable range of offer acceptance rates appear to permit such variability," Choi and colleagues noted.

"There is a need that we believe is urgent to understand the root causes of the wide variability in donor acceptance rates. Public reporting of acceptance rates may be a start," suggested Clyde Yancy, MD, MSc, of Northwestern University Feinberg School of Medicine, Chicago, and Gregg Fonarow, MD, of University of California, Los Angeles, in an .

The retrospective study of the U.S. National Transplant Registry included match runs from 2007-2017 that resulted in transplant, excluding offers that were bypassed (i.e., an organ first offered to a lower-rank candidate) and those that went to transplant centers receiving fewer than 10 first-rank offers in a year.

In total, there were 93 transplant centers reporting 9,628 first-rank candidates that received offers from 19,703 unique donors.

Among those who declined their first-rank offers, 75.5% did subsequently undergo transplant within a year, whereas 8.1% were removed from the waitlist owing to death or decompensation.

The retrospective design couldn't rule out potential unmeasured confounding (e.g., surgeon experience, time elapsed between when the candidate was added to the waitlist and when the patient received their initial first-rank offer), Choi's group acknowledged.

"Those data must be interpreted carefully. The decision to accept a donor heart is complex and requires both experiential insight and careful judgment by physicians experienced at performing heart transplants," according to Yancy and Fonarow.

"Nevertheless, a concern remains that an overly conservative donor acceptance strategy may place patients waiting for transplant at a survival disadvantage. Recognizing the comparable long-term outcomes for hearts passed over for first-ranked organ offers argues against this logic and instead prompts more standardization in donor acceptance strategies," they wrote.

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