Innovations in Heart Transplantation: A Review

•Heart transplantation offers a cure for patients with advanced heart failure.•Innovations in organ procurement and allocation have expanded the donor pool.•The donor pool has also been expanded by donation after circulatory death donation and donors with hepatitis C.•Advances in donor–recipient matching and transplant care have improved outcomes. Advanced heart failure affects tens of thousands of people in the United States alone with high morbidity and mortality. Cardiac transplantation offers the best treatment strategy, but has been limited historically by donor availability. Recently, there have been significant advances in organ allocation, donor–recipient matching, organ preservation, and expansion of the donor pool. The current heart allocation system prioritizes the sickest patients to minimize waitlist mortality. Advances in donor organ selection, including predicted heart mass calculations and more sophisticated antibody detection methods for allosensitized patients, offer more effective matching of donors and recipients. Innovations in organ preservation such as with organ preservation systems have widened the donor pool geographically. The use of donors with hepatitis C is possible with the advent of effective direct-acting antiviral agents to cure donor-transmitted hepatitis C. Finally, further expansion of the donor pool is occurring with the use of higher risk donors with advanced age, medical comorbidities, and left ventricular dysfunction and advances in donation after circulatory death. This review provides an update on the new technologies and transplantation strategies that serve to widen the donor pool and more effectively match donors and recipients so that heart transplant candidates may derive the best outcomes from heart transplantation. [Display omitted] Visual Take Home Graphic: Chronological advances in cardiac transplantation. Chronological illustration of the expansion of the heart donor pool and technologies in heart transplantation.