Donor Heart Acceptance by Race and Gender on Transplant Waitlist

Quick Takes

  • Disparities exist in when donor heart offers are accepted by transplant centers for patients listed for heart transplantation.
  • Acceptance of the first offer for a donor heart was highest in White women (17.5%; 95% CI, 16.0-18.9%) followed by Black women (14.0%; 95% CI, 12.1-15.8%), White men (10.3%; 95% CI, 9.6-11.0%), and Black men (7.9%; 95% CI, 7.0%-8.8%). These trends persisted through the 50th offer.

Study Questions:

For patients on the heart transplant waiting list, what association does race and gender have with the probability of donor heart offers being accepted?


This study used the United Network for Organ Sharing (UNOS) dataset from October 2018 to March 2023. Adult heart transplant candidates listed for a single organ were included. Baseline donor, patient, and transplant center data were collected. Analysis was limited to patients with a stated race and ethnicity of either non-Hispanic Black or non-Hispanic White, and to match runs that ultimately resulted in an organ being accepted for transplant. The primary outcome of the study was the number of offers a heart transplant candidate received until first acceptance of a donor heart. Differences in this outcome were compared by candidate race and gender.


This study included 14,890 waitlisted heart transplant candidates. Among these candidates, 4,608 (30.9%) were Black, 10,282 (69.1%) were White, 10,956 (73.6%) were men, and 3,934 (26.4%) were women. A total of 159,177 offers were made for 13,760 donor hearts.

In the overall cohort, 11.4% (95% confidence interval [CI], 10.8-11.9%) of candidates had the first organ offer accepted. Cumulative incidence curves by race and gender demonstrated significant differences in organ offer acceptance. First organ offer acceptance was highest in White women (17.5%; 95% CI, 16.0-18.9%) followed by Black women (14.0%; 95% CI, 12.1-15.8%), White men (10.3%; 95% CI, 9.6-11.0%), and Black men (7.9%; 95% CI, 7.0%-8.8%). This trend continued up to the 50th offer. Median number of offers until acceptance was lowest for White women (5; 95% CI, 5-6) followed by Black women (7; 95% CI, 6-8), White men (9; 95% CI, 9-9), and Black men (11; 95% CI, 11-12).

After multivariable adjustment, odds of first donor heart offer acceptance were lower for Black compared to White candidates (odds ratio [OR], 0.76; 95% CI, 0.69-0.84), and this difference remained significant through the 16th offer. Odds of first donor heart offer acceptance were higher for women compared to men (OR, 1.53; 95% CI, 1.39-1.68), and this difference remained significant through the 6th offer. For 10th through 31st offers, the odds of offer acceptance were lower for women compared to men.


Among candidates on the heart transplant waitlist, the cumulative incidence of donor heart offer acceptance was highest for White women followed by Black women, White men, and Black men, highlighting disparities in care for this population.


The transplant community continues to strive towards more equitable care for the end-stage heart failure population. Prior studies have highlighted disparities in the transplant listing process, but less is known about how these disparities persist as patients are awaiting transplant. The authors set out to understand differences in how organ offers are accepted during this period prior to transplant. Despite adjusting for many important factors, differences were noted in donor heart offer acceptance when separated by race and gender. While there are many factors not captured by the UNOS dataset that can confound these findings, it is important to consider how transplant center–level practices and biases can contribute to the inequities in care. Future research will be needed to identify and contextualize the key factors that contribute to these disparities, which will better inform what interventions are needed to address modifiable factors.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Cardiac Surgery and Heart Failure, Heart Transplant

Keywords: Health Status Disparities, Heart Transplantation

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