Heart Allocation in the United States

Abstract

The consequences of our actions are so complicated, so diverse, that predicting the future is a very difficult business indeed. —J.K. Rowling, British Novelist (1965–present) Nearly 20 years ago, clinical leaders in the field of heart transplantation met in Bethesda, Maryland, to address the growing disconnect between the numbers of patients with end-stage heart failure who were listed for cardiac transplant and those who actually received transplants.1 As stated by Dr Norman Shumway in his keynote address to the conference, “The principle issue that stands before us is the donor problem.” The severity of the crisis at the time was reflected in the fact that more patients were listed on any given date than underwent transplantation in the previous year. In an effort to ease the supply-demand mismatch, conference leaders developed objective criteria for candidate listing and prioritization, suggested new strategies to improve survival on the waiting list, and broadened donor selection. Despite these initiatives as well as the intensification of efforts toward public education, the actual number of transplants leveled off and has remained flat for more than a decade.2 Prioritization on the waiting list, however, has continued to evolve. In 1989, a simplified algorithm was implemented with 2 categories for medical urgency, and in 1999, a 3-tiered system (status 1A, 1B, and 2) was approved to address perceptions of unfairness in heart allocation. Most recently, the US allocation system was modified in 2006 to allow broader regional sharing of donor hearts to status 1A and 1B patients before allocating organs to local status 2 patients (Table).3 The primary objective of this algorithm change was to decrease wait-list mortality without effecting a change in posttransplant mortality. Article see p 249 View this table: Table. Initial Sequence of Adult Heart Allocation Over the past decade, there has been a slow, …