Transplantation provides a survival benefit in listed patients on VA-ECMO even if posttransplant survival remains inferior than for patients without VA-ECMO. Transplantation may be considered to be an acceptable primary therapy in selected patients on VA-ECMO.

The new French heart allocation system is designed to minimize waitlist mortality and extend the donor pool without a detrimental effect on posttransplant survival. This study was designed to construct a 1‐year posttransplant graft‐loss risk score incorporating recipient and donor characteristics. The study included all adult first single‐organ recipients transplanted between 2010 and 2014 (N = 1776). This population was randomly divided in a 2:1 ratio into derivation and validation cohorts. The association of variables with 1‐year graft loss was determined with a mixed Cox model with center as random effect. The predictors were used to generate a transplant‐risk score (TRS). Donor‐recipient matching was assessed using 2 separate recipient‐ and donor‐risk scores. Factors associated with 1‐year graft loss were recipient age >50 years, valvular cardiomyopathy and congenital heart disease, previous cardiac surgery, diabetes, mechanical ventilation, glomerular filtration rate and bilirubin, donor age >55 years, and donor sex: female. The C‐index of the final model was 0.70. Correlation between observed and predicted graft loss rate was excellent for the overall cohort (r = 0.90). Hearts from high‐risk donors transplanted to low‐risk recipients had similar survival as those from low‐risk donors. The TRS provides an accurate prediction of 1‐year graft‐loss risk and allows optimal donor‐recipient matching.

| INTRODUC TI ONAlthough heart transplantation is the most effective treatment for selected patients with refractory heart failure, access to transplants remains limited by the shortage of heart donors. Currently, in France, the median posttransplant survival is 12 years, with two candidates for one graft and a 1-year waitlist mortality of 11%. 1 In this setting, the new French heart allocation system, implemented in 2018, was designed to minimize waitlist mortality and extend the donor pool while maintaining posttransplant survival. | PRE VI OUS ALLO C ATI ON SYS TEMS IN FR A N CEThe first heart allocation system implemented in France was almost exclusively based on geography with successively local, regional, and national organ sharing, only taking donor and recipient ABO blood types into account. 2 This system was not fair owing to procurement and waitlisting regional disparities in addition to differences in candidate profile from one center to another. In 2004, a novel system was introduced offering hearts first to candidates in immediate life-threatening condition through national priorities. Grafts not allocated through high-urgency (HU) status were then offered to elective candidates according to geography. HU status based on treatment modalities were granted to patients on inotrope infusion or short-term mechanical circulatory support (MCS) (HU1 status), patients on durable MCS with device-related complications (HU2), and patients on uncomplicated biventricular assist device (BiVAD) or total artificial heart (TAH) (HU3). HU status was requested by transplant centers, and HU1 and 2 statuses were granted for periods of 4 and 16 days, respectively. This urgency tier-based allocation system is currently the most widely used heart allocation system in the world. [3][4][5] Graft allocation rules for heart transplantation are necessary because of the shortage of heart donors, resulting in high waitlist mortality. The Agence de la biomédecine is the agency in charge of the organ allocation system in France. Assessment of the 2004 urgency-based allocation system identified challenging limitations. A new system based on a score ranking all candidates was implemented in January 2018. In the revised system, medical urgency is defined according to candidate characteristics rather than the treatment modalities, and an interplay between urgency, donor-recipient matching, and geographic sharing was introduced. In this article, we describe in detail the new allocation system and compare these allocation rules to Eurotransplant and US allocation policies. K E Y W O R D Sethics and public policy, health services and outcomes research, heart transplantation/ cardiology, organ allocation, organ procurement and allocation, waitlist management

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The candidate risk score provides an accurate objective prediction of waitlist mortality. It is currently being used to develop a modified cardiac allocation system in France.