Perspective:

This is a large analysis of mandatory data collected on all cardiac transplants that take place within the United States. As with other cardiac interventions, center experience appears to impact patient outcome within 1 year of cardiac transplant, especially in those patients who are high risk. The curves separate early (within 90 days), suggesting that patient selection, operative experience, and perioperative management strategies may differ by center experience. In a field where the actual intervention is rare (~3,500 per year in the United States) due to donor scarcity, ensuring favorable outcomes is key for both patients and the field of cardiac transplant. Center volume, however, is not only limited by the density of transplant centers (organ donor or patient competition) within a state, but also by the population density and/or radius of available donors. Donor ischemic time cannot be compromised by consolidation of transplant centers, and patients need center proximity to ensure follow-up of biopsies and other post-transplant testing. Higher-risk patients may benefit from referral to larger-volume centers. The use (or reasons for disuse) of left ventricular assist devices in these higher-risk patients should also be investigated.