*Purpose: The decline of organs upon assessment within the field complicates optimal organ and resource utilization. We aimed to investigate if certain donor factors were associated with the in-field decline of heart allografts.

*Methods: We utilized the United Network for Organ Sharing Standard Transplant Analysis and Research database to identify all heart allograft offers from adult donors between 1987 and March 2020. We compared hearts that were declined after in-field assessment to those that were accepted for transplant during the same time period. Categorical variables were compared via chi-squared tests, and continuous variables were compared with t-tests. A multivariate logistic regression model was used to ascertain the impact of particular donor characteristics on the likelihood of in-field heart decline.

*Results: Between 1987 and March 2020, 1,586 hearts were declined following evaluation in the field, while 61,871 hearts were transplanted. Hearts that were declined were more often from older donors (37±11 vs 33±11 years, p<0.001) with higher BMI (27.8±6.4 vs 26.6±5.6, p<0.001). The cause of death for donors of declined hearts was more often anoxia (26 vs 17%, p<0.001) or cerebrovascular accident (33 vs 25%, p<0.001). Donors of declined hearts also more often had a clinical infection (64 vs 49%, p<0.001), required inotropic support (42 vs 35%, p<0.001), and had a history of cocaine use (19 vs 12%, p<0.001). A smaller proportion of donors of declined hearts had an AB blood type (0.4% vs 2%, p<0.001). In a multivariate logistic regression model developed from factors significant by univariate assessment, we found that death via natural circumstances (OR 1.34, p=0.008), Public Health Service increased-risk designation (OR 1.27, p=0.001), total bilirubin (OR 1.05, p=0.001), donor age (OR 1.03, p<0.001), and serum BUN (OR 1.01, p<0.001) were associated with a higher odds of in-field heart decline.

*Conclusions: Direct in-field evaluation of heart allografts is essential prior to organ acceptance. However, we have identified risk factors that may warrant further investigation prior to allocating limited healthcare resources. Understanding the potential influence of these variables on in-field decline may ultimately contribute to streamlining organ allocation and procurement processes.

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