Balancing supply and demand: Review of the 2018 donor heart allocation policy

Abstract

Heart transplant remains the most effective treatment for patients with end stage heart failure. Advances in mechanical circulatory support devices have changed the therapeutic landscape and contributed to a demographic shift in patients awaiting transplant. In the setting of a growing waitlist and concern for an inability of current policies to accurately account for patient acuity and equitable geographic distribution of organs, the United Network for Organ Sharing developed a new donor heart allocation policy which was introduced in 2018. The new policy creates more precise listing criteria to reflect patient acuity, addresses previously marginalized groups, and takes steps to address geographic inequalities.

Changes in multiorgan heart transplants following the 2018 allocation policy change

“…However this led to several problems such as a disproportionate increase in the number of status 1A activations, a wide range of waitlist mortality within status levels, and longer waitlist times 6 . October 2018 marked a change in the heart allocation policy that saw an expansion and refinement of the previous tiers into a 6‐tiered system that prioritizes patients with urgent need 8 . This includes patients on veno‐arterial ECMO, surgically implanted biventricular support devices that cannot be discharged home, or MCSDs with life‐threatening ventricular arrhythmia (status 1) as well as patients on the waitlist for multiorgan transplantation within the same institution without life threatening conditions or circulatory support (status 5) 4 .…”

Molecules, Machines, and the Perfusate Milieu: Organ Preservation and Emerging Concepts for Heart Transplant

“…[1][2][3][4] Limiting ischemia time (be it cold or warm) and adequate preservation of the donor organ remain vital to ensuring the best outcomes for heart transplant. 1,2 Currently, cold static storage is the mainstay for cardiac preservation and transport for most heart transplants performed in the United States. After aortic cross-clamping at the procurement, a crystalloid-based preservation solution is flushed into the aortic root, perfusing the coronary system to provide hypothermic arrest of metabolism, preserve myocyte cellular components, and minimize ischemic reperfusion injury.…”

Exploring the ripples of the 2018 organ allocation policy change

“…Second, the intention of the policy change, namely to more accurately account for patient illness while reducing the geographic inequity in the previous allocation system, was certainly a laudable one 5 . This analysis by Patel et al emphasizes the reality that while such policy changes may be made with the best intentions, there will ultimately be ripple effects from such changes with broad impacts for providers and patients alike.…”