Background: In Switzerland, heart transplantation is limited by donor availability. Marginal donor hearts-characterized by older age, comorbidities, or reduced left ventricular ejection fraction (LVEF)-are often declined despite being structurally normal. Since impaired LVEF may be reversible, optimized donor management could improve cardiac function and transplant eligibility.

Methods: This retrospective cohort study analyzed 415 brain-dead donors (2017-2021) from the Swiss Organ Allocation System. Donors were categorized as optimal (LVEF ≥50%) or marginal (LVEF 15-49%), irrespective of structural abnormalities, to focus on a modifiable functional parameter. Predictors of heart transplantation were assessed using univariate and multivariable logistic regression. Additional analyses evaluated hemodynamic monitoring, diagnostic strategies, management duration, and functional recovery based on serial echocardiography.

Results: Among 415 donors, 287 were optimal and 62 marginal. Transplantation rates were higher in optimal hearts (62.7% vs. 23.6%, p < 0.001). LVEF ≥50% independently predicted transplantation (adjusted OR = 4.56; 95% CI: 2.34-8.89; p < 0.001), together with younger age, lower norepinephrine dose, central monitoring, and repeated echocardiography. Marginal hearts demonstrated significant improvement in LVEF after optimized management (p < 0.0001), suggesting that reversible dysfunction can be mitigated through tailored hemodynamic and pharmacologic strategies.

Conclusions: Optimized donor management can restore left ventricular function in marginal hearts and enhance transplant eligibility. Standardized national guidelines may help expand the donor pool and improve transplantation outcomes.