Novel Strategies Can Enable Fair Access to Heart Transplantation

Geography, for patients in need of transplant, once shaped destiny—the distance between two centers, even when separated by a short drive, could determine outcomes.

In the early part of my career as a heart transplant cardiologist, geographic boundaries, specifically Donor Service Areas (DSAs), played a decisive role in access to timely treatment within the United States. Originally designed to define regions for donor–recipient matching and minimize travel times (and thus ischemic injury), this strategy to prioritize by location also produced unintended barriers.

Patients within a DSA with high donor registration rates and a high-performing Organ Procurement Organization (OPO) could often be transplanted from home. Yet just miles away, in a neighboring DSA, high-acuity hospitalized patients died on the wait list due to lower donor registration rates (sometimes driven by state-level differences) and poorer OPO performance.

These disparities were further compounded by insurance status. When transplant opportunities differed markedly between neighboring states, patients with Medicaid were often restricted to in-state transplantation, while those with private insurance could pursue dual listing. As a result, DSAs unintentionally created a system in which geographic boundaries shaped access not only by location, but also by socioeconomic status.

In 2018, however, a new heart allocation policy debuted. By design, it eliminated fixed geographic zones and instead prioritized medical urgency supported by broader regional and national sharing. The intention was to ensure that organs reached the sickest patients first, regardless of arbitrary distance-based boundaries. As the system shifted to broader sharing, those geographic barriers have, in large part, faded.

While broader sharing has improved access to organs for the sickest, it also has had negative consequences: increased costs associated with travel, risk to procurement or recovery teams, and increased ischemic injury associated with long travel times.

This underscores why policy making must be iterative, responsive to outcomes—intended and unintended—and must be driven by a multidisciplinary group of experts that includes the physicians, surgeons, and nurses taking care of the waitlisted patients. Crucially, this process must be informed by donor families, ethicists, government, and OPO professionals.

Innovation Improves Access

Fair access to heart transplantation is increasingly shaped not only by medical urgency or allocation rules, but by a center’s ability to adopt and sustain innovation, particularly advanced organ-preservation technologies needed for long-distance procurement travel and for donation after circulatory death (DCD) transplant.

The expansion of DCD and the rapid growth of perfusion and preservation platforms have revolutionized what is possible. In many transplant centers, DCD now accounts for more than a third of annual transplant volume. Five or 6 years ago, that number was zero. Organ perfusion devices and other procurement technology, as well as translational science, have further expanded the viable donor pool by allowing long-distance recovery, improved assessment, and more controlled preservation.

Yet these advances are not evenly distributed. Some centers have embraced multiple preservation and procurement platforms and already have integrated them into routine practice. Others have only recently begun their first DCD cases, and many still have no program in place at all. This variation is not driven by clinical philosophy; it is driven by resource availability, staffing, training, and operational bandwidth.

No matter the DCD procurement modality—whether by direct procurement and perfusion with normothermic preservation, with normothermic regional perfusion followed by hypo- or normothermic preservation, or via even more nuanced approaches using hyperoxygenated cold flush followed by cold storage—program capacity building is essential to increase volume and save more lives.

The Importance of Program Scale

Transplant centers are diverse ecosystems. Smaller programs are essential, often serving regions where patients cannot easily travel to urban academic centers, but lower volume inherently limits the ability to bring new platforms online. Smaller-volume programs have fewer physicians, surgeons, nurses, advanced practice providers, and administrators as well as less research infrastructure. Time is required to learn new technology and platforms, develop program capacity, and make fundamental changes in practices—time to participate in national meetings, time to identify peer mentors and collaborating centers, time to steer a program through change, and time for budget negotiation.

All of this comes at a different type of cost. Importantly, small centers tend to be more conservative in recipient and donor selection, as adverse outcomes (which are expected in any center, despite outstanding staff and programmatic structure) have a greater impact on nationally reported quality measures.

Larger centers, by contrast, can more readily absorb the training, travel, and device-management demands associated with long-distance procurement and the integration of multiple preservation systems. A program with six implanting surgeons and multiple procurement teams can accept and utilize offers that a two-surgeon program simply cannot.

A 2025 study published in the American Journal of Transplantation found that center-specific factors, including volume, structure, and organ-offer acceptance behavior, were major drivers of differences in wait-list mortality and transplant rates, even under uniform national allocation guidelines. While this paper focused on kidney transplant, similar observations have been made across all organ programs.

Importantly, two patients with similar clinical severity may experience very different time-to-transplant trajectories depending on whether their program can deploy the technologies that now define modern donor utilization.

To say it plainly: the primary barrier to access has shifted. What was once a geographically driven disparity has evolved into a capability-driven one, determined by how effectively a center can adopt and operationalize modern and innovative donor-utilization tools.

Structural Factors Compound Barriers

Variations in center capability do not exist in isolation. They interact with wider demographic and socioeconomic realities. A recent study in Journal of Heart and Lung Transplantation examining the newest heart-allocation system found that patients of low socioeconomic status (SES) remained significantly less likely to undergo transplantation and experienced inferior post-transplant outcomes compared with higher-SES counterparts. This reinforces that fair access depends not only on patient acuity or listing status, but also on center capability and operational support.

Allocation policy alone cannot resolve these differences, and it is not intended to. The system in place rightly prioritizes medical urgency, but it cannot equalize the structural differences that exist across transplant centers.

National statistics from the 2023 OPTN/SRTR Annual Data Report, the most recent report available, highlight this reality. In 2023, there were 4,092 adult heart transplants performed in the United States, but substantial variation in patient experience remains. Adult wait-list mortality reached a national average of 8.5 deaths per 100 patient-years, yet transplant rates differed meaningfully across demographic groups and across metropolitan versus nonmetropolitan areas.

These patterns reinforce that fair access depends not only on policy design but also on the infrastructure, staffing, and technological capability of the program caring for the patient. When technological capability varies, opportunity varies even when the allocation algorithm performs exactly as intended.

This is the quiet reality: in today’s landscape, access to innovation has become a defining determinant of fair access.

Closing the Gap Through Shared Infrastructure

If we want to maintain fair access for patients across all regions, we need to think holistically about how programs can support one another.

• Partnerships between high- and lower-volume centers (shared education, co-developed protocols, procurement collaboration) can help more patients benefit from the technologies shaping donor availability.
• The growing presence of external retrieval teams and preservation specialists is another way to distribute capability more evenly without requiring each program to independently build every platform.
• We must continue responsibly expanding the donor pool. Many donors who fall outside historical norms are now viable thanks to preservation technology.

Using these organs safely and confidently can reduce wait-list mortality and ease the pressures that force centers to be overly selective.

Why Coming Together Matters

The rapid evolution of transplant innovation demands an equally rapid exchange of experience. Communal spaces, such as the American Transplant Congress, are invaluable in that they bring together surgeons, physicians, OPO partners, preservation scientists, policymakers, and other stakeholders in one room. These individuals rarely share space but unquestionably share responsibility. In-person conversations allow us to compare real-world outcomes, evaluate emerging technologies, and work through the operational realities that ultimately shape patient care.

Innovation is moving fast. To ensure fair access keeps pace, we must move together.

 

Off Script is a first-person blog written by leading voices in the field of cardiology. It does not reflect the editorial position of TCTMD.