National Organ Procurement and Transplant Network Heart Allocation Policy: 6 Years Later.

In 2014, the Organ Procurement and Transplant Network began reappraisal of the United States heart transplant allocation policy. Driven by ongoing discordance between organ supply and demand, high waitlist mortality, and increasing exception requests, the Thoracic Committee radically redesigned the priority scheme and drafted a 6-tiered algorithm, included durable device complications into policy, expanded broader sharing, and increased the number of mandatory listing variables to develop a future heart allocation score. This became the 2018 New Heart Allocation Policy. Changes in allocation priority have resulted in a significant increase in the use of temporary mechanical circulatory support in waitlisted candidates with a concomitant decrease in the number of patients bridged to transplanted with durable left ventricular assist device support. The number of exception requests continues to increase, particularly for patients listed status 2 and for multiorgan transplants. Importantly, fewer patients are being delisted for clinical improvement, suggesting missed opportunities for recovery. The current review will critically evaluate the 2018 heart allocation policy 6 years later, briefly focusing on the history of heart allocation in the United States, the current and evolving algorithms for candidate prioritization including continuous distribution, the impact of technology and innovation on transplant rates and future policy development, and the ongoing regulatory oversight and governance changes in the Organ Procurement and Transplant Network.