Optimal and Equitable Allocation of Donor Hearts: Which Principles Are We Translating Into Practices?

Selection of heart transplantation (HTx) candidates should take into account the need and the probability of success of transplantation. The output of a process that is focused on the careful evaluation of individuals, per international experts' recommendations,1 is by the end, the building of a group, because each patient that is deemed eligible and deserving of an HTx is added to the others on a transplant waitlist. Conversely, organ allocation criteria are defined within each country, considering ethical principles and societal values besides strictly medical considerations.2,3 The output of this process is the assignment of single hearts to single patients. Balancing the best interests of individual with a community's interests may be a difficult task when the gap between demand and supply is wide, as in the case with HTx. Local heart allocation per the “first come, first serve” rule has been progressively abandoned in favor of broader organ sharing and urgency-based prioritization to reduce inequalities and meet the patient needs (Table (Table1).1). The increasing proportion of patients undergoing HTx in critical conditions could limit posttransplant survival without reducing the waitlist mortality, ultimately worsening overall patient outcomes.