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Outcomes following hepatitis C virus (HCV)‐viremic heart transplantation into HCV‐negative recipients with HCV treatment are good. We assessed cost‐effectiveness between cohorts of transplant recipients willing and unwilling to receive HCV‐viremic hearts. Markov model simulated long‐term outcomes among HCV‐negative patients on the transplant waitlist. We compared costs (2018 USD) and health outcomes (quality‐adjusted life‐years, QALYs) between cohorts willing to accept any heart and those willing to accept only HCV‐negative hearts. We assumed 4.9% HCV‐viremic donor prevalence. Patients receiving HCV‐viremic hearts were treated, assuming $39 600/treatment with 95% cure. Incremental cost‐effectiveness ratios (ICERs) were compared to a $100 000/QALY gained willingness‐to‐pay threshold. Sensitivity analyses included stratification by blood type or region and potential negative consequences of receipt of HCV‐viremic hearts. Compared to accepting only HCV‐negative hearts, accepting any heart gained 0.14 life‐years and 0.11 QALYs, while increasing costs by $9418/patient. Accepting any heart was cost effective (ICER $85 602/QALY gained). Results were robust to all transplant regions and blood types, except type AB. Accepting any heart remained cost effective provided posttransplant mortality and costs among those receiving HCV‐viremic hearts were not >7% higher compared to HCV‐negative hearts. Willingness to accept HCV‐viremic hearts for transplantation into HCV‐negative recipients is cost effective and improves clinical outcomes.

Objective: To test the hypothesis that exercise and dobutamine would provide levels of cardiac stress that are comparable to those achieved in a general stress test population, and to one another, in heart transplant recipients. Patients and Methods: From February 10, 2015, to December 31, 2017, 81 patients underwent exercise stress (N¼45) or dobutamine stress (N¼36) echocardiography at a mean AE SD of 11AE14 years (range, 1-29 years) after heart transplant. Hemodynamic and inotropic responses were compared between groups, and to a prior test, longitudinally. The primary outcome was peak heart rate (HR) Â systolic blood pressure (SBP). Results: Peak exercise HR Â SBP Â 10 À3 was a mean AE SD of 24.9AE4.9 mm Hg/min for exercise stress vs 21.2AE3.4 mm Hg/min during dobutamine stress (P<.001). In 35 patients who underwent a dobutamine stress test followed later by another dobutamine stress test, peak HR Â SBP changed by 4.2%AE16% (P¼.05). In 25 patients who underwent a dobutamine stress test followed later by an exercise stress test, peak HR Â SBP increased by 12%AE23% (P¼.002 vs serial dobutamine stress tests). Peak exercise HR did not correlate with time since heart transplant, patient age, or graft age. Peak dobutamine HR correlated modestly with patient age (r 2 ¼0.28). Inotropic responses were similar in both groups. Overall, patients preferred exercise stress testing to dobutamine stress tests. Dobutamine stress testing was more expensive than exercise stress tests. Conclusion: Exercise induces a level of cardiac stress that is equal to or greater than dobutamine-induced stress, at lower cost, in heart transplant recipients who express preference for exercise stress testing.

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