Introduction: Scarcity of grafts for Heart Transplantation (HTX), the high mortality rate in waiting lists, the high prevalence of recipients in priority status and the limited capacity of the transplant system to provide grafts, pushes transplant teams, specially those in high volume centers around the world, to frequently use hearts with long ischemic times. 
Objective: Characterize and evaluate results with recipients undergoing HTX using grafts with ischemic time equal to or greater than 4 hours, in a high-volume center in Brazil. 
Material and Methods: Results were evaluated through an observational retrospective cohort study, from 2013 to 2024, with 528 HTX, of which 111 used hearts with ischemia time equal to or greater than 4 hours. The outcomes evaluated were: graft dysfunction rate, 30-day mortality, and survival rate after 5 and 10 years post-HTX. Demographic, reading, and laboratory data were obtained from hospital records. The distribution was assessed by the Shapiro-Wilk test and the paired Student's t-test was used to compare the postoperative ejection fraction and the use of lnotropes at two moments, immediately after surgery and four days postoperatively (PO).
Results: A total of 528 consecutive HTX were analyzed (2013 to 2024), all using cold static protection with Bretschneider's solution. 111 HTX (21,02%) were performed using hearts with more than 4 hours ischemic time. 96 HTX (86,5%) with ischemia between 4 and 5 hours and 15 HTX (13,5%) with more than 5 hours. All patients were adults, 64% male, mean age was 45.5 years (SD=12.6; 95% CI 42.8 - 48.0) and the mean body mass index was 23.7 kg/cm². The most prevalent etiology was idiopathic (36%), followed by Chagas (33%). 65.6% of the recipients used Mechanical Circulatory Support (MCS), with the intra-aortic balloon pump (IABP) being the most prevalent (53.8% of cases). 31.10% of the recipients had only inotropes as a support. The Pre HTX exams showed that 36% had hemoglobin under 10 g/dl, 32% had creatlnln of 1.4 mg/dL or higher, and 20% had glycoslated hemoglobin above 6.5%. We observed that, in the postoperative day period (POD), the need for inotropes was significantly reduced by the 4th POD compared to the dosage used immediately after the HTX (P=0.0001). We observed an improvement in ejection fraction, at Echocardiogram, with significant recovery at the 4th POD (P=0.008). We also bserved severe graft dysfunction rate of 9%. The 30-day mortality rate was 18 recipients (17%), with infection being the main cause of death {88%). The 5-year survival rate was 68%, and the end-10-year survival rate was 62%.
Conclusions: We conclude that, in a high-volume center, with a high rate of priority enrolled recipients, especially those supported with MCS, in our opinion, it is fully justified the use of hearts with more than 4 hours of ischemia, especially considering the acceptable incidence of graft dysfunction, as well as the good survival rate at 5 and 10 years after HTX.