*Purpose: To examine the clinical impact and cost-effectiveness of hepatitis C viremic (HCV+) heart organ donation in the United States.

*Methods: We used a microsimulation model to compare 2 heart transplant waitlist strategies in 2018: status quo (SQ) and SQ plus HCV+ donors (SQ+HCV). We used national datasets to model mean age (53 years), male sex (75%), probabilities of waitlist mortality (0.01-0.10/month) and transplant (0.03-0.21/month) stratified by medical urgency, and post-transplant mortality (0.01-0.07/month). We assumed a 23% donor pool increase with SQ+HCV using estimates of donor HCV+ prevalence. Costs (in USD) included waitlist care ($2,200­-190,000/month), transplant ($213,400), 4-week HCV treatment ($26,000), and post-transplant care ($2,500-11,300/month). We projected waitlist time, quality-adjusted life-years (QALYs), lifetime costs, and incremental cost-effectiveness ratios (ICERs [$/QALY, discounted 3%/year]; threshold ≤$100,000/QALY).

*Results: Compared to SQ, SQ+HCV decreased waitlist time (8.7 to 6.7 months), increased QALYs (8.9 to 9.2 QALYs), increased discounted lifetime costs ($671,400 to $690,000/person), and led to an ICER of $74,100/QALY (Figure 1). Urgent listing candidates had greater QALY gains vs. emergent listing candidates (0.4 vs. 0.3 QALYs) due to greater absolute decreases in waitlist time. The ICER remained ≤$100,000/QALY with ≤20% increases in transplant and post-transplant costs. HCV treatment was 1% of lifetime costs (Figure 2).

*Conclusions: Transplanting HCV+ donor hearts into uninfected recipients would decrease waitlist times, increase life expectancy, and be cost-effective. These findings were robust within the context of current HCV treatment costs.

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