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According to Organ Procurement Transplant Network policy, hearts from donors age <18 years are offered to pediatric recipients before being offered to adults of the same health status. We aimed to analyze differences in the use of adolescent donor hearts between adult and pediatric candidates and also to analyze the outcomes of pediatric candidates in which an adolescent donor heart was refused and later used in an adult recipient.All adolescent donors (age 12-17 years) for 2000 to 2015 were identified using the standard United Network of Organ Sharing dataset and matched against the Potential Transplant Recipient dataset.Of the 2457 adults who received an adolescent heart, 855 (35%) received it after at least 1 refusal by a pediatric candidate (n = 844). Of the 844 pediatric candidates, 643 (76%) subsequently underwent transplantation (designated PCTs) and 201 (24%) never underwent transplantation (designated PCNTs). Among the latter group, 87 patients (43%) died or became too ill for transplantation. These 87 PCNTs refused 256 hearts that were later accepted by adult recipients. Donor quality was the most common reason for refusal. Overall, adult recipients had similar post-transplantation survival compared with PCTs, all pediatric transplants, and all adult transplants (P > .10). A breakdown of adolescent heart donors by year shows a trend toward increased use in pediatric candidates.A significant number of adolescent donor hearts that are refused by pediatric centers result in excellent post-transplantation outcomes in adult recipients. One in 10 pediatric candidates died on the waitlist after refusal of these hearts used by adult recipients. This warrants careful evaluation of the refusal criteria used by pediatric centers. Encouragingly, there now appears to be a trend toward an increased use of adolescent donor hearts by pediatric centers.