*Purpose: There remains a disparity between the number of patients awaiting heart transplantation (HTx) and the availability of donor hearts. This is exacerbated by relatively low rates of donor heart utilization, partly because of a reluctance to accept extended criteria organs. Many of these so-called extended criteria have been shown not to impact outcomes. We sought to determine whether extended criteria have a cumulative effect on recipient outcomes.

*Methods: Between 2012 and 2017, we assessed 626 HTx extended criteria donors, defined as donor age >50 yrs, left ventricular (LV) hypertrophy >1.2cm, LV ejection fraction (LVEF) <50%, ischemic time >4 hours, donor-transmitted coronary artery disease (CAD), female-to-male gender mismatch, and donor:recipient weight <0.80. We then divided recipients into four groups according to the number of criteria present: 0 (n=350), 1 (n=220), 2 (n=76), ≥3 (n=15). We assessed each group for 3-year actuarial survival, freedom from cardiac allograft vasculopathy (CAV), freedom from any-treated rejection and freedom from non-fatal major adverse cardiac events (NF-MACE: MI, CHF, stroke, and need for angioplasty or pacemaker/ICD).

*Results: There was no difference in 3-year actuarial survival, 3-year freedom from CAV and 3-year freedom from any-treated rejection between the groups. However, there was progressively worse freedom from NF-MACE as the number of extended criteria increased (82.5% vs 74.8% vs 59.3% vs 54.6%; p=0.035). The most common extended criterion in group 2 was donor age (56/220), the most common combination of 2 criteria in group 3 was age and CAD (19/76) and the most common combination of 3 criteria in group 4 was LV hypertrophy, gender mismatch and CAD (4/15).

*Conclusions: In an attempt to expand the donor pool, numerous single-center series have demonstrated good outcomes for extended criteria organs. We show acceptable outcomes for donor organs with multiple extended criteria. However, we found that risk of NF-MACE incrementally increased with the number of criteria. These findings suggest that donors with one or even two or more extended criteria are acceptable for use, although complication rates may be higher.

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