As society is ageing, an increasing prevalence of elderly heart failure patients will be expected. In order to increase the donor pool, acceptance of older donors might be a reasonable choice. All patients undergoing heart transplantation between 2010 and 2021 at a single department were retrospectively reviewed and divided into different study groups with regard to recipient (≤60 years (RY) or >60 years (RO)) and donor age (≤50 years (DY) or >50 years (DO). A total of n = 201 patients were included (DY/RY, n = 91; DO/RY, n = 38; DY/RO, n = 41; DO/RO, n = 31). Neither incidence of severe primary graft dysfunction (p = 0.64) nor adverse events, such as kidney failure (p = 0.27), neurological complications (p = 0.63), infections (p = 0.21) or acute graft rejection (p = 1.00), differed between the groups. However, one-year survival was impaired in the DO/RO group (56.0%) compared to the other groups (DY/RY: 86.1%, DY/RO: 78.8%, DO/RY: 74.2%, p = 0.02). Given the impaired one-year survival, acceptance of grafts from old donors for old recipients should be performed with caution and by experienced centres only. Nevertheless, because of the otherwise dismal prognosis of elderly heart failure patients, transplantation of patients may still improve the therapy outcome.