Cleveland Clinic expert proposes global heart allocation to address health inequities

Today at the 46th Annual Meeting and Scientific Sessions of the International Society for Heart and Lung Transplantation (ISHLT), Eileen Hsich, MD, of the Cleveland Clinic, outlined a bold vision for the future of heart transplantation that moves beyond national borders to address global inequities in organ allocation.

In her talk, Dr. Hsich argued that persistent disparities in access to heart transplantation-and the underutilization of donor hearts-demand a rethinking of current allocation systems.

Moving toward heart allocation on a global scale

"Across the world, there is a fundamental mismatch between the number of patients waiting for a heart transplant and the number of transplants performed," said Dr. Hsich, Professor of Medicine and Medical Director for Heart Transplantation at the Cleveland Clinic.

If we want to reduce waitlist deaths and improve equity, we need to rethink how we allocate and utilize donor hearts, potentially on a global scale."

Eileen Hsich, International Society for Heart and Lung Transplantation

Data presented from ISHLT and United States-based registries highlight ongoing disparities. Socioeconomic status plays an increasing role, with lower-income patients experiencing higher waitlist mortality and reduced access to transplantation.

"These disparities reflect the difference between equality and equity," Dr. Hsich said. "True equity requires that the population receiving transplants matches the population in need. That's not just equal access, but appropriate access."

Wealthier countries perform significantly more heart transplants than lower-income regions, despite similar or greater need. Countries like Canada demonstrate an effective alignment between transplant rates and waitlist demand.

To improve utilization of available organs, Dr. Hsich said emerging tools such as the Donor Utilization Score (DUS) can help identify donor hearts suitable for transplantation.

"We already have tools to better assess donor heart quality," she said. "The next step is ensuring we use as many viable hearts as possible."

Technologies enable donor organs to remain viable longer

Advances in organ preservation and transport offer the potential for donor organs to travel further distances to where they're most needed. Technologies such as normothermic machine perfusion and cold oxygenated perfusion are continually lengthening the time donor organs can be kept viable, thereby enabling international travel.

Dr. Hsich pointed to a recent transatlantic transplant case in which a donor heart was successfully transported from the West Indies to Paris and implanted in a 70-year-old recipient who recovered well and was discharged within 30 days.

"This is no longer theoretical, it's already happening," she said. "The question is whether we are ready to scale it."

A global allocation system, she noted, would not be unprecedented. International registries such as DKMS have successfully facilitated more than 125,000 bone marrow transplants worldwide, demonstrating the feasibility of cross-border organ matching.

However, significant challenges remain. A global heart transplant system would require international cooperation, financial sustainability, regulatory oversight, and agreement on ethical principles such as reciprocity and fairness.

"Globalization raises important ethical questions," Dr. Hsich said. "We must ensure that any system promotes equity, maintains quality, and delivers strong outcomes for patients everywhere."

ISHLT uniquely positioned to lead global allocation efforts

She suggested that ISHLT is uniquely positioned to lead such an effort, given its global membership, scientific expertise, and existing registry infrastructure.

"With the right governance and collaboration, we can build an international system that reduces disparities and ensures no viable donor heart goes unused," she said.

The annual meeting and scientific sessions of the ISHLT are being held from 22–25 April at the Metro Toronto Convention Centre in Toronto, ON, Canada.