Purpose: Despite advances in heart transplantation, organ procurement organizations (OPOs) continue to struggle with the deleterious effects of the brain death cascade on the pathophysiologic function of donor hearts. Even previously well-functioning hearts often present with left ventricular ejection fractions (LVEF) less than 40% at the beginning of donor management. While studies have proven there is no increase in recipient mortality when donor heart function improves over time and is subsequently transplanted, there are no widely used methods to recruit donor hearts and increase transplantation. 
Methods: This OPO adapted a specialized protocol to recruit donor hearts with the intent of improving the LVEF and overall cardiac function. Under the direction of the medical director and the advanced practice coordinator, the protocol was first implemented in 2022, and more widely adopted in 2023. Similar to common practices in the treatment of myocardial stunning after cardiopulmonary bypass, milrinone, epinephrine, nitroprusside, and dobutamine (named MEND protocol), along with select other medications, were utilized in addition to specific guidelines for donor fluid status, temperature, hemodynamic monitoring, and timelines for resuscitation. Each brain-dead donor with heart transplant potential was screened at case start to assess the current LVEF. If LVEF was less than 50%, the MEND protocol was initiated. If the LVEF remained less than 50% after 12 hours of the MEND protocol, a second round was initiated. While there are continuous improvements to the protocol, the basis of optimizing preload, contractility and afterload to expedite cardiac recruitment remains the same. 
Results: During the initial stages of implementation, four donor hearts were recruited utilizing the MEND protocol in 2022. Three of those hearts went on to transplantation. In 2023, sixteen hearts were recruited and eleven were transplanted. The average initial LVEF ranged from 30-35% at case start, and LVEF after recruitment ranged from 55-60%. Following initiation of the MEND protocol, cardiac function improved on average within 48 hours. Prior to recruitment and use of the MEND protocol, these hearts were deemed not suitable for transplant due to poor cardiac function. 
Conclusions: As the OPO landscape changes and organizations seek to find new ways to increase organ utilization, OPOs must consider implementing practices that improve organ function for organs that have previously been deemed non-transplantable. The MEND protocol has allowed this OPO to far exceed its expected heart transplant yield for 2023 and is expanding the definition of transplantable.