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To expand the donor pool, older donors (≥50 yr) are frequently used in older recipients (≥60 yr). Older recipients and those receiving older donor hearts have independently displayed decreased post-transplant survival. However, outcomes in older patients receiving older donor hearts are contentious.Eight hundred and seventy-nine heart transplant patients between 2000 and 2010 were analyzed, excluding patients with donor coronary artery disease. From 380 patients ≥60 yr, 327 patients with donors <50 yr old were compared with 53 patients with donors ≥50 yr old for: five-yr actuarial survival, freedom from cardiac allograft vasculopathy (CAV: stenosis ≥30%), non-fatal major adverse cardiac events (NF-MACE: MI, CHF, stroke, need for pacemaker/ICD), one-yr freedom from any treated rejection.The older vs. younger donor group demonstrated significantly lower five-yr survival (57% vs. 85%, p < 0.001) and freedom from CAV (83% vs. 92%, p = 0.03). No difference was observed in five-yr freedom from NF-MACE and one-yr freedom from any treated rejection. Multivariate analysis found donor age ≥50 to be an independent risk factor for death (HR 1.8, CI 1.1–2.9, p = 0.008) and CAV (HR 1.9, CI 1.2–2.9, p = 0.004).Use of older donors (≥50 yr) in older recipients (≥60 yr) results in lower five-yr survival and freedom from CAV. Caution is required in these cases. Larger studies are warranted to confirm findings.