Unintended Shifts in High-Priority Adult Heart Transplant Listings after the OPTN's September 2025 Policy Change.

The Organ Procurement and Transplantation Network amended Status 2 heart allocation criteria in September 2025, requiring documented failure of high-dose inotropes before candidates could qualify via intra-aortic balloon pump (IABP) or percutaneous endovascular ventricular assist device (PEVAD) support. Using OPTN data, we compared seasonally matched pre-policy (September 2024-June 2025, n=4,206) and post-policy (September 2025-June 2026, n=4,231) adult candidates. While standard Status 3 high-dose inotrope listings increased 2.0% to 4.1% and standard Status 2 IABP/PEVAD listings decreased 18.2% to 11.0%, Status 1 listings and Status 2 exceptions increased 7.7% to 10.6% and 17.5% to 21.5%, respectively (all p<0.001). Consequently, combined initial Status 1/2 listings were unchanged (44.5% vs 44.0%, p=0.71). Furthermore, overall transplant volume remained similar, but status at transplant shifted from standard Status 2 toward Status 2 exceptions and Status 1. Tightening standard Status 2 eligibility was associated with redistribution across high-priority pathways rather than reduced high-priority listings.