Old may still be gold: 45- to 55-year-old donors yield safe early outcomes in adult heart transplantation.

Objective: Advanced donor age is a common reason for donor heart offer turndown, especially in donation after circulatory death donors. With advancements in donor heart preservation and perioperative management strategies, the association between donor age and heart transplant outcomes in the current era is unclear. Methods: This was a single-center study of all adult heart transplants from January 2020 to June 2025. The cohort was stratified by donors aged less than 45 years versus donors aged 45 years or more. A subgroup analysis compared donation after brain death donors aged 45 years or more and donation after circulatory death donors aged 45 years or more. Propensity score matching created balanced cohorts. Outcomes of interest included primary graft dysfunction, measures of early graft function and index hospitalization course, and up to 1-year survival. Results: A total of 784 transplants were included in this study, of which 676 (86.2%) were in the standard donor group and 108 (13.8%) were in the old donor group. After 1:1 propensity matching, rates of primary graft dysfunction, cardiac indices and inotropic requirements, ventilation duration, and intensive care unit and hospital lengths of stay were comparable between the group. One-year mortality was also similar (10.2% donors aged <45 years vs 7.4% donors aged ≥45 years, Conclusions: In the modern era, adult heart transplantation using donors aged 45 years or more yields safe early outcomes. Outcomes between old donation after brain death and donation after circulatory death donors were also comparable, despite the historical hesitancy around old donation after circulatory death donors.