A Pressure Valve in the Allocation System: Understanding Out-of-Sequence Heart Allocation

In solid organ transplantation, donor organs are distributed to recipients via a waitlist with recipient rank determined by a combination of urgency and time accrued on the list. ( Network, Organ Procurement and Transplantation 2025 ) Out-of-sequence (OOS) allocation places donor organs outside the standard algorithmic match run, theoretically expediting placement of time-sensitive or harder-to-match allografts, resulting in bypassing candidates higher on the waitlist. Although OOS allocation has become more common in abdominal organ transplantation, its use, drivers, and consequences in heart transplantation have not been well characterized. In this study, Benkert and colleagues present the first comprehensive national analysis of OOS donor heart allocation in the United States. ( Benkert et al., 2025 ) Their work offers important insight into a rare but growing practice that is reshaping access to transplantation for select patients, many of whom are clinically stable, yet disadvantaged, under the current allocation framework.