Reasons for donor heart offer refusal are often unrelated to the donor itself - when, why, and the "weekend effect".

BACKGROUND

Most donor hearts offered for heart transplant (HT) in the United States (US) are turned down. We aimed to understand the reasons for this - focusing on those related to the potential recipient and HT center (i.e., donor-unrelated reasons for refusal).

METHODS

The Donor Heart Study (DHS) enrolled 4,333 adult potential heart donors in US from 2015 to 2020. Separately by donor, each HT center who refused an offer for that donor was surveyed on their reason(s) for refusal. We measured the prevalences of 18 distinct donor-unrelated reasons for refusal and their association with the timing of offers (weekend vs. weekday).

RESULTS

Our analytic sample included 14,132 unique surveys, each representing a declined offer for one of 3,083 donors (mean per donor: 2.56; range: 1-17). Donor-unrelated reasons were cited in 24.3% (n = 3,441) of surveys; among these, recipient issues (i.e., "recipient ill) were most common (cited in 7%) while resource-related issues (e.g., "logistics", "surgeon unavailable") were rare (<1%). Neither showed a significant time trend; however, other reasons ("already considering another offer", "distance too far") did so, with an abrupt uptick after 2018. We found that several donor-related (but no donor-unrelated) reasons for refusal (e.g., left ventricular hypertrophy, social risk behaviors) were significantly more common on weekends. Their "weekend-predominance" was not explained by differences in objective donor characteristics.

CONCLUSIONS

Nearly one quarter of donor heart offer refusals are due to donor-unrelated reasons. Weekend-predominant reasons for offer refusal signal the highly subjective nature of donor assessment and warrant further scrutiny.