Cardiac transplantation (HTX) is the gold standard and is an increasingly utilized therapy for patients with end-stage heart failure (1). Strategies to reduce the risk of waitlist mortality remain urgently needed. The Public Health Service defines increased risk donors (IRDs) as donors who carry an increased risk for inadvertent window-period disease transmission to a transplant recipient, specifically human immunodeficiency virus, hepatitis B virus, and hepatitis C virus (2). IRDs represent an increasing fraction of the donor pool, to 19.5% in 2015 (3). Outcomes regarding the use of IRD allografts remain scarce in HTX. Single-center data have not identified adverse long-term outcomes or an increased rate of disease transmission (4). However, the comparison between standard and IRD allografts is fundamentally incorrect from the perspective of the waitlist candidate, as the decline of an IRD offer is associated not with an immediate non-IRD alternative offer, but instead with the prospect of additional waitlist time of uncertain duration before a suitable offer becomes available. To ascertain the effect of the decline of IRD organ offers to HTX candidates, we performed a retrospective registry analysis to examine competing-risks outcomes for candidates that declined IRD organ offers. Following institutional review board approval, we performed a retrospective cohort analysis using United Network of Organ Sharing data for adult isolated HTX candidates who received an offer for an IRD allograft from 2007 to 2017. To measure the risks of competing outcomes following IRD offer decline, we followed candidates who declined an IRD offer from the time of response until eventual IRD or non-IRD HTX, death or decompensation precluding HTX, or administrative censoring. To determine the survival benefit associated with acceptance of the IRD offer, we identified candidates who accepted the IRD offer, and compared