1. What Patients Should Know About the New Adult Heart Allocation System
Centers: please use this slide deck in your patient education

2. How are hearts matched now?
Three medical urgency statuses:
1A (most urgent) 1B
2 (least urgent)
Exceptions for some candidates
Biological matching (blood type, size)
Distance from donor hospital
Waiting time is “tiebreaker”
Let’s start by describing the heart allocation system as it is now. Some parts of the system will change and some won’t.
Once the transplant hospital accepts you and lists you for a heart transplant, you’re assigned a medical urgency status. This status is based on specific medical criteria that estimates how urgently you need a transplant. Your urgency status may go up or down based on changes in your overall health or current treatment you are getting.
Right now there are three medical urgency statuses – 1A, which is the most urgent, 1B and 2. Status 2 is the least urgent.
You might have special medical needs or issues that the standard policy does not address. In this case, your transplant team can ask for an exception to list you in a status that better reflects how urgently you need a transplant. A review board of medical experts considers your team’s request based only on your medical information, not other personal information about you.
As donor hearts become available, they are offered first to candidates who:
are listed at a transplant hospital near to the donor hospital – we’ll address that part more in a moment.
are a match with the donor’s blood type
are the most medically urgent
For any candidates who match a nearby donor, the transplant team gets more detailed medical information about the organ offer. The team may accept the offer or decline it. They might decline the offer because the candidate is too sick at the moment to be transplanted, or because certain medical facts suggest the organ wouldn’t be a good match.
If there are no local matches for urgent candidates, or if no local programs accept a heart offer, candidates who match the donor but are listed at hospitals farther from the donor hospital will get offers next.
The most medically urgent candidates (Status 1) are considered first, followed by less urgent candidates who are a good match to the donor. At any level of match, if two or more candidates share the same status, then the person who has been waiting the longest in their status gets priority.

3. Heart Geographic Distribution
> 2500
2500
1500
1000
500
Local
Donated hearts are most likely to function if they’re transplanted within 4 to 6 hours of being recovered from the donor. We want to keep preservation time as short as possible. This means we try first to match up patients who are very close to the donor hospital.
The first level of matching is within the same donor service area, or DSA, where the donor is located. The UW Health Transplant Program is served by UW Organ and Tissue Donation, one of the nation’s highest performing organ procurement organizations. You can learn more about their service area at uwotd.org
If there are no matching local patients, or if the transplant surgeon declines the offer for local patients, the next level of matching is for patients at hospitals within 500 nautical miles of the donor hospital. If no one accepts the organ offer at that level, it then goes to anyone within 1,000 miles, and so on. Most donated hearts, if they’re not used locally, will go to a recipient within 1,000 miles.

4. Why are changes needed? Changes in treatment of heart disease
More use of support devices or therapies (ECMO, VAD, artificial heart)
Better understanding of how patients do on devices
Better understanding of candidate risk without a transplant
More categories allow more precise distinction of urgency
Goal to reduce waiting list deaths
Transplant most urgent patients the soonest; broaden their access to available hearts
As we learn more about heart disease and how to successfully treat it, we need more specific criteria that reflects a patient’s current health and care they are getting.

5. Implementation dates September 18, 2018 October 18, 2018
Phase 1 – Your team will begin submitting information that justifies your new status
October 18, 2018
Phase 2 – Your new status will be used to match you with your new heart
When we implement this first phase, transplant teams will have time to enter the newly required data for all their candidates. Having this data ready and in the system will ensure that their candidates receive the proper urgency status once the policy is fully implemented on October 18.

6. What will change? Six new medical urgency statuses instead of three
More specific criteria to qualify
Distribute hearts up to 500 miles for new Statuses 1 and 2
You won’t lose any waiting time from before
Beginning in October 2018, candidates will be listed according to six medical urgency statuses. Status 1 is the most urgent and Status 6 is the least urgent. While there are highly detailed criteria for status assignments, the allocation process considers several basic factors:
If you are in the new Status 1 or 2, you are in the most urgent need for a heart transplant. As a result, you would be considered first for heart offers from a wider geographic area (up to 500 miles from the donor location) before candidates with Status 3, 4, 5 or 6.
Your status may change if your symptoms get better or worse, or if your form of treatment changes. If you had been in a higher status but no longer meet the criteria for it, your transplant team will change your status as appropriate. You should talk directly with your transplant team for current information regarding your status and any treatment options.

7. What will NOT change? Urgency statuses for pediatric candidates
Medical matching criteria (blood type, size, etc.)

8. What are the expected outcomes?
More transplants for the sickest candidates
More refined priority for the very sickest
Wider access to donors for the very sickest
Will monitor and improve system as needed
What do we expect the new system to do?
First of all, it should lower the number of people who die awaiting a heart transplant. The sicker a patient is, the higher the chance is that he or she will die on the list. So the increased priority for the sickest patients should reduce deaths overall.
Also, even with double the number of statuses, the new criteria should result in having fewer patients in the two highest statuses – One and Two. To give these very sick patients the best of chance of being transplanted, they will have early access to some donors who are farther from their hospital than the old system allowed. But at the same time, having fewer of these patients overall means more hearts should be available to transplant patients at lower urgency statuses.
It’s important for you to know that as soon as this new system goes into place, UNOS and heart programs will be studying how it is doing. Who is getting transplanted? How many are getting transplanted? How long are people waiting? Are there unintended effects? UNOS is committed to making additional changes to the policy if it doesn’t change things for heart patients nationwide.

9. Factors that influence urgency status
Likely higher if…
Likely lower if…
You’re currently on ECMO
You’re not on ECMO
You have an implanted device (artificial heart or VAD) PLUS one or more of the following:
You must stay in the hospital
You’re having device-related complications
Your device has recently been replaced
You either don’t have an implanted device (artificial heart or VAD), or you have one AND:
You’re stable enough to leave the hospital
You aren’t having major complications
You have been on the device longer-term
You are on medications to stimulate heart function
You don’t need heart-stimulating medication
You have life-threatening, irregular heart function (tachycardia, fibrillation, arrhythmia)
You currently don’t have life-threatening irregular heart function
You need one or more additional organs (such as a lung or liver)
You don’t need any additional organs
There are very detailed criteria that affect what status you’ll be listed in. If you want to see the specifics, we have them listed in later slides. But, in general, here are the things that are likely to affect your score the most.
If you are on one or more advanced support therapies (such as ECMO, VAD or an artificial heart), and/or if you have a difficult to control, life- threatening condition such as ventricular arrhythmia, tachycardia or fibrillation, then you will have higher priority.
If your current treatment is complicated by an infection or clotting, or if you have to stay in the hospital, then you will generally be in a higher status than those who are not having complications and can leave the hospital.
The transplant program reports data to UNOS about your current treatment and symptoms. The program then lists you in the applicable status.
Depending on changes in your condition or your treatment, your status can go up or down.
Your status may go up or down as your condition changes.
Your transplant team can tell you how these factors affect your individual score.

10. What do I need to do?
Be aware of changes – ask transplant team any questions
Let your team know of any complications or concerns
Make sure you attend all your doctors’ appointments
It’s important that your transplant center has your most current information and test results. Please work with your transplant team to schedule appointments and tests that will allow them to keep your information up to date.
Keep in mind that if you have had an exception score before the policy changes over, your transplant team may need new or additional tests or other information to put in a new exception request.

11. How can I find out more? Your transplant team
TransplantLiving.org (UNOS site for patients and caregivers)
Organ facts>Heart>Heart Q&A
( )
UNOS Patient Services: (888)

12. How does exception process work?
Transplant team provides medical information to review board
Review board will now be from a different region of the country
Considered on medical facts only (no personal or hospital information provided to reviewers)
Transplant team may appeal decision if it chooses
Exceptions can be renewed
More urgent exceptions require more frequent renewals and updated information/test results from the transplant hospital
Exception and extension requests will be sent to regional review boards. The only change here is that under the old system, the review board came from doctors within the same UNOS region as the hospital where the patient is listed. In the new system, the review board that reviews exception or extension requests will be from a different region.
All requests for an exception or extension are considered only on medical facts. The review board doesn’t get names or personal information about the patient and doesn’t even know what center submitted the request.
If an initial exception request is turned down, the transplant team has the right to appeal the decision. That’s not a guarantee that the appeal will be granted, but it’s not a forever one-time decision.
Exception status is generally good for a specific period of time. If that time frame runs out and the patient still qualifies, the transplant team can ask for an extension. But, keep in mind that if the exception status is more urgent, the team will have to renew the request more often and probably have more frequent tests done.

13. Criteria for medical urgency statuses
VA ECMO
Non-dischargeable, surgically implanted, non-endovascular biventricular support device
MCSD with life-threatening ventricular arrhythmia
Status 2
Non-dischargeable, surgically implanted, non-endovascular LVAD
IABP
V-tach / V-fib, mechanical support not required
MCSD with device malfunction/mechanical failure
TAH, BiVAD, RVAD, or VAD for single ventricle patients
Percutaneous endovascular MCSD

14. Criteria for medical urgency statuses
Dischargeable LVAD for discretionary 30 days
Multiple inotropes or single high-dose inotrope with continuous hemodynamic monitoring
VA ECMO after 7 days; percutaneous endovascular circulatory support device or IABP after 14 days
Non-dischargeable, surgically implanted, non-endovascular LVAD after 14 days
MCSD with one of the following:
device infection
hemolysis
pump thrombosis
right heart failure
mucosal bleeding
aortic insufficiency

15. Criteria for medical urgency statuses
Dischargeable LVAD without discretionary 30 days
Inotropes without hemodynamic monitoring
Re-transplant
Diagnosis of one of the following:
congenital heart disease (CHD)
ischemic heart disease with intractable angina
hypertrophic cardiomyopathy
restrictive cardiomyopathy
amyloidosis

16. Criteria for medical urgency statuses
On the waitlist for at least one other organ at the same hospital
Status 6
All remaining active candidates