Impact of the 2018 U.S. Heart Transplant Listing Priority Policy on Survival
Impact of the 2018 U.S. Heart Transplant Listing Priority Policy on Survival
Source: AHA. Based on JACC: Heart Failure – July 2025
Background
In 2018, the United States restructured its heart transplant system to improve fairness and prioritize the sickest patients.
• Old system (before 2018): 3 tiers or categories —
• Status 1A: very urgent (often with aggressive support).
• Status 1B: intermediate.
• Status 2: all other active candidates.
• In the old U.S. system (before 2018), Status 1A was meant only for the very sickest patients.
• But transplant centers realized that if they gave patients high-dose medicines (inotropes) or placed temporary support devices (like balloon pumps), those patients could automatically qualify for 1A.
• As a result, too many patients were listed as 1A, even if some were not truly the sickest.
• This made Status 1A overcrowded and less useful for distinguishing who really needed the heart most urgently.
• New system (after 2018): Expanded to 6 statuses (1–6) for finer separation:
• Status 1: sickest (e.g., ECMO, ventilator).
• Status 2–3: very urgent (balloon pump, high-dose inotropes).
• Status 4–6: less urgent, stable patients.
• Goal: ensure donor hearts go first to those at highest true risk.
Study Design
• Observational analysis of 23,043 adult candidates using the SRTR database.
• Pre-policy cohort: Oct 2013–Oct 2016 (11,022 patients).
• Post-policy cohort: Oct 2018–Oct 2021 (12,021 patients).
• Main outcome: 3-year survival benefit = extra days alive with transplant vs. waitlist.
Results
1. More transplants, faster:
• 65% → 74% of patients received a transplant.
• Average waiting time fell from 220 → 129 days.
2. Survival benefit doubled for the sickest:
• Old Status 1A = 328 days → New Status 1 = 699 days gained.
3. Overall improvement:
• Average benefit per transplant: 217 → 241 days.
• First 3 years: 1,645 extra life-years saved nationwide.
Conclusion
The 2018 U.S. Listing Priority Policy achieved its main goal: better sorting of patients by urgency, reduced waiting time, and significant increases in survival benefit — especially for the sickest candidates.
Relevance for JCS:
This experience shows how refining transplant listing criteria can maximize the impact of scarce donor organs. Developing region-specific policies in Jordan and the Middle East could similarly ensure that hearts reach the most urgent patients first, saving more lives and aligning national practice with global best standards.
