Young at heart: favorable outcomes in selected older heart transplant recipients

Purpose Heart transplantation (HT) in older recipients raises uncertainty regarding futility risk and ethical concerns related to other candidates. This study aimed to describe the characteristics and outcomes of older recipients in our cohort. Methods A retrospective analysis was conducted on 711 adult HT performed at a single center between 1988 and 2024. Patients aged ≥65 years were classified as “older recipients.” Results The older recipient group (N=78, 11%) showed a growing number of transplants over time (p<0.01). Among them, 65 were male (82%, p=0.34), and ischemic cardiomyopathy remained the leading indication (41% vs. 53%, p=0.7). This group had a higher prevalence of diabetes (30%, p<0.01), pulmonary hypertension (62%, p=0.02), and sensitization (25%, p=0.05), along with longer ischemic times (median 216 [158–260] minutes, p=0.03). Older recipients experienced a higher incidence of severe primary graft dysfunction (14% vs. 6.5%, p=0.02) and worse creatinine levels at one year (1.34 vs. 1.2 mg/dL, p=0.04). In contrast, they had lower rates of cardiac allograft vasculopathy (11% vs. 26%, p=0.04) and acute rejection (9% vs. 12%, p=0.4). Notably, donor age was not significantly associated with survival within this group (HR 0.99, p=0.41). Although recipient age was an independent risk factor in Cox multivariate regression analysis (HR 1.02 [1.01–1.03], p<0.01), no significant differences were observed in 1-year (73% vs. 67%, p=0.26) or 10-year survival (Figure 1, p=0.27). Conclusion HT appears to be a feasible option with comparable long-term outcomes in carefully selected older recipients, regardless of donor age and with a more favorable immunologic risk profile, despite an increased risk of short-term complications.