| INTRODUC TI ONAlthough heart transplantation is the most effective treatment for selected patients with refractory heart failure, access to transplants remains limited by the shortage of heart donors. Currently, in France, the median posttransplant survival is 12 years, with two candidates for one graft and a 1-year waitlist mortality of 11%. 1 In this setting, the new French heart allocation system, implemented in 2018, was designed to minimize waitlist mortality and extend the donor pool while maintaining posttransplant survival.
| PRE VI OUS ALLO C ATI ON SYS TEMS IN FR A N CEThe first heart allocation system implemented in France was almost exclusively based on geography with successively local, regional, and national organ sharing, only taking donor and recipient ABO blood types into account. 2 This system was not fair owing to procurement and waitlisting regional disparities in addition to differences in candidate profile from one center to another. In 2004, a novel system was introduced offering hearts first to candidates in immediate life-threatening condition through national priorities. Grafts not allocated through high-urgency (HU) status were then offered to elective candidates according to geography. HU status based on treatment modalities were granted to patients on inotrope infusion or short-term mechanical circulatory support (MCS) (HU1 status), patients on durable MCS with device-related complications (HU2), and patients on uncomplicated biventricular assist device (BiVAD) or total artificial heart (TAH) (HU3). HU status was requested by transplant centers, and HU1 and 2 statuses were granted for periods of 4 and 16 days, respectively. This urgency tier-based allocation system is currently the most widely used heart allocation system in the world. [3][4][5] Graft allocation rules for heart transplantation are necessary because of the shortage of heart donors, resulting in high waitlist mortality. The Agence de la biomédecine is the agency in charge of the organ allocation system in France. Assessment of the 2004 urgency-based allocation system identified challenging limitations. A new system based on a score ranking all candidates was implemented in January 2018. In the revised system, medical urgency is defined according to candidate characteristics rather than the treatment modalities, and an interplay between urgency, donor-recipient matching, and geographic sharing was introduced. In this article, we describe in detail the new allocation system and compare these allocation rules to Eurotransplant and US allocation policies.
K E Y W O R D Sethics and public policy, health services and outcomes research, heart transplantation/ cardiology, organ allocation, organ procurement and allocation, waitlist management