J Card Fail. 2026 Sep;32(9):1584-1593. doi: 10.1016/j.cardfail.2026.06.027.
ABSTRACT
The United States heart allocation system prioritizes transplant candidates using therapy-based categorical urgency tiers that measure treatment decisions rather than biological risk. This miscalibration is associated with observable downstream issues: status exception rates exceeding 40% of adult listings, systematic escalation of temporary mechanical circulatory support in hemodynamically stable candidates, missed opportunities for myocardial recovery, and structural inequities in access. This review argues that meaningful reform requires a sequenced agenda: developing validated continuous urgency scores grounded in objective biological variables for both adult and pediatric candidates, reforming the exception process through standardized prospectively applied criteria, and building a new allocation policy using accurate inputs.
PMID:42710972 | DOI:10.1016/j.cardfail.2026.06.027