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Many acceptable donor hearts are turned down by pediatric centers with varying criteria for an acceptable donor. Advanced Cardiac Therapy Improving Outcome Network (ACTION) and Pediatric Heart Transplant Society (PHTS) centers convened a multi-institutional donor decision discussion forum (DDDF) aimed at assessing donor acceptance practice and reducing practice variation across centers. The team hosted an hour-long monthly virtual DDDF among pediatric transplant centers across North America, UK and Brazil. Each call had two case presentations posing a donor decision challenge for the presenting center at the time of donor offer. Following each presentation, the attendee group was polled to obtain insight on donor acceptance practices after which the presenting center's decision was revealed. Then, group discussion occurred including a review of relevant literature and latest PHTS data related to the case. Metrics of participation, participant agreement with presenting center decision and impact on future decision making were collected and analyzed. Over 14 months, 23 cases were discussed; an average of 50 physicians, nurses and fellows attended each call. The mean donor age was 8.2 ± 3.3 years (28.6% infants, 52.4% young adults), and the mean recipient age was 8.36 ± 3.3 years (27.3% infants and 40.9% teenagers). Reason for listing was congenital heart disease in 10, cardiomyopathy in 5 and retransplantation in 3. Risk factors influencing decision making included size discrepancy (4), Infection (5), COVID (2), Prolonged QT (2), Malignancy (2), Drugs (2), Distance (1) Prolonged CPR (1) high inotrope use (1) Dialysis (1) Diabetes (1) HLA mismatch (1). Of the 23 cases, 15 were declined by presenting center. Donor characteristics influenced 45% of the decisions and recipient only 20%, with rest being other factors. Participants agreed with the decision made by the presenting center 55% of the times. The post-presentation discussion resulted in 30% of participants changing their original decision. DDDF identified significant variation in pediatric donor acceptance practices; with donor characteristics most influential in decision-making. Given that the discussions changed decisions in 1/3rd of the participants, DDDF may be a useful format to reduce practice variation, provide education to decision makers and eventually increase donor utilization. [ABSTRACT FROM AUTHOR]