Rethinking heart transplant allocation: Aligning urgency, equity, and outcomes.

Since the implementation of the new allocation system for heart transplantation in 2018, various unintended consequences have emerged. In response, a recent policy amendment was proposed that took effect in September 2025 requiring transplant programs to document failure of inotropic therapy prior to the use of percutaneous endovascular mechanical circulatory support or intra-aortic balloon pump. The goal of this new policy is to reduce inflation and waitlist congestion of Status 2 and help to further risk stratify patients within the current Status 2 tier by waitlist urgency. This viewpoint highlights the potential anticipated challenges in response to this policy including rising exception requests, gaming of timing, potential delays in appropriate escalation of mechanical circulatory support, and considerations around health equity.