Novel Strategies Can Enable Fair Access to Heart Transplantation

Why It Matters

Access to life‑saving heart transplants now hinges on institutional capability, directly influencing patient outcomes and health‑care equity across socioeconomic groups.

Key Takeaways

• 2018 allocation policy eliminated fixed geographic zones
• Center volume dictates adoption of preservation technologies
• DCD transplants now exceed one‑third of cases
• Low‑SES patients still face lower transplant rates
• Shared procurement teams can level capability gaps

Pulse Analysis

The 2018 overhaul of the U.S. heart‑allocation system was a watershed moment, replacing donor service areas with urgency‑based sharing across broader regions. While the change succeeded in reducing geographic inequities, it introduced new challenges: longer travel distances increase logistical costs and ischemic risk, demanding sophisticated perfusion and preservation solutions. Centers that quickly integrated normothermic and hypothermic platforms gained a competitive edge in securing offers, reshaping the landscape of transplant access.

Technology adoption has become the decisive factor. Donation after circulatory death (DCD) now accounts for over a third of heart transplants, a leap made possible by portable perfusion devices that maintain organ viability during extended transport. Large academic centers, equipped with multiple surgeons, dedicated procurement teams, and research infrastructure, can absorb the training and operational expenses of these platforms. In contrast, smaller programs face staffing shortages and budget constraints, limiting their ability to offer DCD or long‑distance procurements and consequently raising wait‑list mortality for their patients.

Addressing this capability gap requires systemic collaboration. Partnerships between high‑volume and community hospitals can share expertise, protocols, and even external retrieval teams, allowing lower‑resource centers to access cutting‑edge preservation technology without duplicating capital outlays. National societies and policy makers should incentivize such networks, tying reimbursement to collaborative outcomes and supporting training grants. By aligning incentives with shared infrastructure, the transplant ecosystem can ensure that advances in organ‑preservation translate into equitable access for all patients, regardless of where they receive care.