Commentary: United Network for Organ Sharing policies work, but progress only occurs at the speed of a snail: A need for expeditious adjustments

Central MessageThe current United Network for Organ Sharing allocation policy needs to be remedied expeditiously.See Article page XXX. The current United Network for Organ Sharing allocation policy needs to be remedied expeditiously. See Article page XXX. The first substantive United Network for Organ Sharing policy change to the allocation system since 2005 was implemented in 2018 with the goal of reducing waitlist mortality among the heterogenous groups of patients previously clustered as status 1A. In this issue of the Journal, Singh and colleagues1Singh S.K. Hassanein M. Ning Y. Wang C. Kurlansky P. Clerkin K. et al.Increasing waiting times for status 2 patients in new United Network for Organ Sharing allocation system: impact on waitlist and post-transplant outcomes.J Thorac Cardiovasc Surg. 2023; (XXX:XXX)Abstract Full Text Full Text PDF Scopus (1) Google Scholar evaluate the impact of the new allocation system on waitlist and posttransplant outcomes in patients listed status 2. The marked increase in use of temporary mechanical circulatory support (TMC), particularly intra-aortic balloon pump, facilitating a high transplant rate and shorter wait time while avoiding the necessity of bridging to transplant with a durable left ventricular assist device (LVAD), has been well documented.2O'Connell G. Wang A.S. Kurlansky P. Ning Y. Farr M.A. Sayer G. et al.Impact of UNOS allocation policy changes 675 on utilization and outcomes of patients bridged to heart transplant with intra-aortic balloon pump.Clin Transplant. 2022; 36: e14533https://doi.org/10.1111/ctr.145333Crossref PubMed Scopus (0) Google Scholar,3Yuzefpolskaya M. Schroeder S.E. Houston B.A. Robinson M.R. Gosev I. Reyentovich A. et al.The Society of Thoracic Surgeons INTERMACS 2022 annual report: focus on the 2018 heart transplant allocation system.Ann Thorac Surg. 2023; 115: 311-327Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar The current report confirms this trend with increasing use of microaxial pumps from 2019 to 2022. Not surprisingly, as an increasing number of patients are listed status 2, the wait time has increased (18 days vs 23 days, P < .001) with waitlist mortality remaining stable, likely indicating increasing expertise with prolonged TMC support. The more striking take-home message from this work is the ever-increasing status 2 listing by exception, most recently making up >40% of all status 2 heart listing. Even more remarkable is that >50% of status 2 patient upgrades to status 1 were done by exception. Although the high number of exception requests may reflect the inadequacy of the current system for accommodating the complexities of current patients with heart failure, it also may signify a systematic problem, with centers inappropriately justifying this status in order to avoid LVAD implantation. The problem of excessive exception requests is compounded by the fact that the patients will automatically get listed under the requested status until it is reviewed by the regional review committees. In these cases, it is conceivable that a patient may be transplanted under the higher and possibly unapproved status. This is particularly concerning regarding status 1E, in which case transplant can occur within days. The new allocation policy was meant to reduce the number of exceptions; in this account, it is clearly failing. Furthermore, in the current system, patients with restrictive cardiomyopathy, adult congenital heart disease, those who are highly sensitized, and those in need of retransplantation are inadequately prioritized, particularly given their limited options for TMC or durable LVAD support. The success of the new allocation system lies in its ability to allow patients to proceed directly to transplant if they are sufficiently hemodynamically compromised. Despite some increases in status 2 wait time, outcomes up to 6 months do not appear to be compromised. However, it is possible that the price in greater mortality for longer status 2 waitlist time has not been recognized yet. Excessive and potentially inappropriate status 2E and 1E will disadvantage the patients at a lower status or those who truly have a greater mortality without transplantation. We should continue to adjust and improve the current allocation system to create a more fair and equitable system. Hopefully, it will not take another decade to make this critical change. Increasing waiting times for status 2 patients in new United Network for Organ Sharing allocation system: Impact on waitlist and posttransplant outcomesThe Journal of Thoracic and Cardiovascular SurgeryPreviewSince the heart transplant allocation policy change in 2018, there has been an increase in temporary mechanical circulatory support for Status 2 patients. We sought to examine the temporal pattern of waitlist and posttransplant outcomes for Status 2 patients. Full-Text PDF