<h3>Purpose</h3> We sought to characterize adaptive changes to the revised UNOS heart allocation policy, and estimate long-term survival changes on the waitlist and after heart transplantation (HTx). <h3>Methods</h3> Patients listed for HTx after the new allocation policy (10/18/18 - 3/5/21), as well as patients from the preceding 5 years (10/17/2013 - 10/17/18) were identified from the UNOS database. Sub-analyses were performed for extracorporeal membranous oxygenator (ECMO), durable left ventricular assist device (LVAD), intra-aortic balloon pump (IABP), microaxial support (Impella), and no mechanical support (non-MCS). Survival data were fitted to parametric distributions and extrapolated. <h3>Results</h3> 28,506 patients were on the waitlist (Before: 19,067, After: 9,439), and 18,252 patients underwent HTx (Before: 12,656, After: 5,596). Updated policy resulted in listing more patients on ECMO (3.4% vs. 1.8%, p<0.01), IABP (13.2%, vs 5.2%, p<0.01) and Impella (0.8% vs 0.1% p<0.01), as well as less patients on LVAD (24.4% vs. 28.5%, p<0.01) and non-MCS (55.5% vs. 63.1%, p<0.01). Similarly, more HTx were performed off ECMO (6.2% vs 1%, p<0.01), IABP (32.3% vs. 8.3%, p<0.01), Impella (1.7% vs. 0.1%, p<0.01), and less off LVAD (24.3% vs. 44.3%, p<0.01) and non-MCS (34.3% vs. 43.6%, p<0.01). Waitlist survival improved in the overall population (p<0.01, panel A), LVAD (p<0.05), and non-MCS patients (p<0.01), however it was worse in ECMO (p<0.01 panel B), IABP (p= 0.05), and not significant in Impella (p=0.23). Post-transplant survival was worse in the overall population (p<0.01, panel C), LVAD (p<0.01), IABP (p<0.05), Impella (p<0.01), and non-MCS (p<0.01), however it was better in ECMO (p<0.05, panel D). <h3>Conclusion</h3> Revised policy has led to higher use of temporary support at the expense of durable LVADs and non-MCS. Overall, waitlist survival improved in contrast to worsened post-HTx survival. Increased ECMO use has translated to higher waitlist mortality, albeit better post-HTx survival off ECMO.