Donor heart allocation systems in Europe. A scientific statement of the Heart Failure Association of the ESC.

Heart transplantation remains the gold standard for treatment of most patients with advanced heart failure (HF), but despite improvements of organ recovery and utilization, donor heart scarcity remains a critically limiting factor.

Detailed heart allocation systems (HASs) are in place to ensure use of organs for appropriate candidates, In Europe multiple, different HASs have evolved in different countries or communities of collaborating countries, like Eurotransplant or Scandiatransplant.

In this scientific statement, we review the generic ethical and practical principles underlying allocation principles and examine and describe different European HASs with the purpose of discussing impact of outcomes for patients with advanced HF.

It is shown that European HASs differ significantly with respect to which patients are prioritized and the methods by which the prioritization is performed.

It is argued that the most commonly used parameter to describe success of a HAS, namely 1-year survival after heart transplantation, is a poor metric of HAS performance.

The impact of HASs should be evaluated by several measures such as survival from listing, time to transplantation, the characteristics of patients undergoing heart transplantation, and over a longer time interval to understand the balance of early and late post-transplant risks and benefit.

Mapping European HASs is a step towards understanding these factors and further research should determine the optimal HAS in a given HF population at a given time.