Donor discard rates for pediatric heart transplant (HT) remain high (≈40%), often driven by concerns about elevated donor troponin levels. This study evaluated the association between peak donor troponin levels, donor troponin trends, and post transplant survival among pediatric HT recipients.

Children (aged <18 years at listing) who underwent HT between January 2007, and June 2020 were identified from the Organ Procurement and Transplantation Network registry. Recipient and donor characteristics, as well as 1‐year post‐HT survival, were compared across peak donor troponin I percentiles (0 to <25th, 25th to <75th, ≥75th) and troponin trend categories (increasing, persistently high, persistently low, decreasing).

Among 4572 donors with reported troponin I values, 67% (n=3097) had abnormal levels. Recipients of donors with peak troponin ≥75th percentile were more frequently aged 11 to 17 years (47.1% versus 22.9% versus 33.1%), had implantable cardioverter‐defibrillators (12.8% versus 5.5% versus 8.2%), and exhibited higher creatinine and bilirubin at transplant. Donors with troponin ≥75th percentile were more likely to have undergone cardiopulmonary resuscitation (63.3% versus 44.3% versus 53.7%) and had left ventricular ejection fraction ≤55% (8.7% versus 4.2% versus 6.4%) (P<0.05 for all). In adjusted analyses, peak donor troponin ≥75th percentile was associated with increased 1‐year graft loss (hazard ratio, 1.22 [95% CI, 1.00–1.47]; P=0.045). Troponin trends were not associated with post‐HT graft survival.

Most pediatric HT donors exhibit abnormal troponin levels. Elevated peak donor troponin (>0.66 ng/mL) correlates with donor hemodynamic instability and predicts worse 1‐year post transplant graft survival, whereas troponin trajectories are not prognostic.