Critically appraising the 2018 United Network for Organ Sharing donor allocation policy: adding life boats or rearranging the deck chairs?

Purpose of review Due to the growing mismatch between donor supply and the demand as well as unacceptably high transplant waitlist mortality, the heart organ allocation system has been revised in October 2018. This review gives an overview of the changes in the new heart organ allocation system and its impact on heart transplant practice and outcomes in the United States. Recent findings 2018 heart allocation system offers a 6-tiered policy and therefore prioritizes sickest patients on the transplant waitlist. Patients supported with temporary mechanical circulatory support devices are prioritized as Status 1 or Status 2, which have resulted in increased utilization of this strategy. Patients support with durable left ventricular assist devices have been prioritized as Status 3 or 4, which have resulted in decreased utilization of this strategy. Broader geographic sharing in the new heart allocation system has resulted in prolonged donor ischemic times. Overall, the new heart allocation system has resulted in significantly lower candidate waitlist mortality, shorter waitlist times, and higher incidence of transplantation. Summary The new United Network for Organ Sharing allocation policy confers significant advantages over the prior algorithm, allowing for decreased waitlist times and improved waitlist mortality without major impact on posttransplant survival.