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Another consideration is to create an allocation score. This would change a rule based” system to an “algorithmic based” system. Algorithmic based systems can predict waitlist mortality, such as the Model for End-Stage Liver Disease (MELD score) used for liver transplantation. 54 They can also be constructed to predict both pre-and post-transplant mortality to minimize death on the waitlist and yet prevent futility, such as the lung allocation score (LAS score) for lung transplantation.55 In order to create an algorithmic based allocation system, risk factors must be identified. This task is possible but would be substantial given the number of high-risk groups potentially present and possible interactions with many variables.

Geographic disparity can be reduced by either transporting people or organs across current UNOS regions. Relocating organs may be possible. However; relocating patients is often limited to more affluent individuals, which raises ethical concerns given the need to keep organ allocation fair and equitable to all. Another alternative to reducing geographic disparity is to broaden sharing or reorganize regions to better match the population density with donor availability. The liver transplant allocation system is considering restructuring their program from 11 regions to either 4 or 8 in order to better match organs with high priority recipients. All these attempts have the potential to reduce waitlist mortality but ultimately just rearrange the existing structure. Additional options are needed to make more substantial changes to matching the market.

Ventricular assist devices (VADs) provide an important alternative to transplantation. They have been proven to extend life for both women and men with advanced heart failure48 and shown to be superior to medical therapy for Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) level 4-7.65 Currently, devices are implanted for bridge to transplant and less frequently as destination therapy.66 In fact, many who are “labeled as destination therapy” are later switched to bridge to transplantation.67 The lack of enthusiasm for embracing VADs as permanent alternatives to transplantation is due to the risk of pump thrombosis, stroke and driveline infections.66, 68 So who should receive VADs as an alternative to transplantation? VADs are indicated for patients who are INTERMACS profile 4 or worse, with consistent symptoms of heart failure at rest or minimal activity. The use of VADs or listing for transplantation should also be considered in INTERMACS Profile 5 patients, who are comfortable at rest but have minimal functional reserve, as documented by peak VO2 less than 12-14 ml/kg/min. More research will need to be done to better identify this cohort.

Conclusion

Strategies to better match the market for heart transplantation are necessary to enable a scarce resource to be maximally utilized. There are 3 ways to achieve this goal: 1) increase the donor pool, 2) reduce the waitlist, and 3) improve the allocation system. Although it is easier to focus national efforts on only one strategy, all must be done simultaneously to ensure that the growth of the waitlist matches the number of available donors. Advances in technology should provide better opportunity to engage young people to become organ donors such as Facebook.28 Other social media needs to be explored and more successful programs like state revenue reserved for donation recruitment needs to be encouraged.18

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Minority groups need to be considered separately and successful programs like Dow-Tip should be replicated. These efforts will increase the number of potential donors that “Opt In.” Although it is not clear which method is best in the United States, it is clear that the best donor is young and healthy. Family members are likely to be distraught and surprised when a young person dies and less likely to donate organs voluntarily. Therefore, it may be best to figure out how to have more of these potential donors “Opt In” and make it clear prior to death their wishes to be an organ donor. The waitlist also needs to be reduced and strict uniform criteria based on outcome data will need to be utilized. This will likely be the most difficult aspect. Just because we can transplant a patient with multiple co-morbidities or tobacco abuse we need to remember that we have a limited resource that should be distributed to only those with the best outcome for success. Finally, efforts to improve the allocation system need to be embraced. Objective data to define tiers in my opinion will prevent “gaming the system” and research needs to be done to better determine optimal timing for urgent transplantation in high risk groups like restrictive cardiomyopathy. Alternatives to transplant like the usage of VADs should be considered, especially once patients are identified that have similar survival with either option. Finally, collaboration between many medical and community participants will be vital in order to begin the rematch between supply and demand as we strive for more effective allocation of the scarce resource of human hearts for transplantation.

Supplementary Material

Refer to Web version on PubMed Central for supplementary material.

Acknowledgements

A special thank you to Dr. Lynne Stevenson, who provided suggestions and the inspiration to write this review.

Sources of Funding

Supported by the National Heart, Lung and Blood Institute of the National Institute of Health under Award Number R56HL125420-01A1. The content is solely the responsibility of the author and does not necessarily represent the official views of the National Institutes of Health.

Abbreviations

DOW-TIP Dow Take Initiative Program

HDS Heart Donor Score

HOTA Human Organ Transplant Act

HRSA Health Resources and Services Administration

INTERMACSInteragency Registry for Mechanically Assisted Circulatory Support

OPTN Organ Procurement and Transplantation Network

SRTR Scientific Registry of Transplant Recipients

UNOS United Network for Organ Sharing

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Figure 1.

Organ Donation Registration and The Impact of Facebook Organ Donor Initiative. On May 1, 2012 Facebook launched to 30% of their customers a Facebook “Timeline” platform that included organ donor designation. At that site one could link to educational information and state registration. Upon registering, potential donor's “network of friends” was notified of the change in status. Figure A. Graphs the Facebook Initiative and the effect on new online registration compared to those who were already an organ donor at time of Facebook usage. Figure B. Compares the effect of online Facebook registration to Department of Motor Vehicle registration. Copied from Cameron et al.28

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Figure 3.

Cardiac Transplant Research Database: Adults Heart Transplantation and the Effect of Donor Hypertension (A) or Diabetes Mellitus (B) and Gender. The cohort consists of 7,322 patients from 32 heart transplant centers who were transplanted between 1990-2007. Copied from Stehlik et al33

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Figure 5.

Scientific Registry of Transplant Recipients: Mortality on Waiting List For Heart Transplantation from 2002-2013. Figure A. Mortality stratified by UNOS Status. Figure B. Mortality stratified by presence of a ventricular assist device. Adapted from Colvin-Adams et al39

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Figure 6.

Scientific Registry of Transplant Recipients: Gender Differences in Survival on Heart Transplant Waiting List from 2000-2009. Adapted from SRTR data61

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Figure 7.

Scientific Registry of Transplant Recipients Between 2000-2010: Survival on Heart Transplant Waiting list based on Type of Cardiomyopathy. Copied from Hsich et al63

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