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Will Status 2 Become the New 1A?

The practice of advanced heart failure changed dramatically in the United States with the introduction of a new heart transplant allocation system on October 18, 2018. The new allocation system provided further stratification of patients at the top of the transplant list (ie, Status 1A under the previous system was stratified to new Statuses 1, 2, and 3), a change that allowed organs to be allocated more quickly to the sickest of patients. With this change, the use of temporary support in patients who underwent cardiac transplant rose dramatically from 10% to 41%.1 In each analysis published thus far, waitlist mortality has decreased under the new allocation system.1–3 The most recent analyses of the impact of the allocation system change on postcardiac transplant mortality have produced hazard ratios (HRs) between 1.18 and 1.4, the latter being the largest study to date (n=1311; HR, 1.4 [95% CI, 1.01–1.95], P=0.04).2,3 Although these measures of association are an improvement over earlier estimates, a harm signal continues to be present and CIs remain relatively wide.