Abstract
The nature and size of the heart transplant waiting list has changed over recent years, most obviously with a larger number of patients on the list with ventricular assist devices (VADs). Given the limited numbers of available donors it is time to re-evaluate who is actually placed on the list. Evidence suggests that many patients with stable ambulatory heart failure might have a limited survival benefit from heart transplantation, so these patients may be an obvious target when considering how to reduce the size of the list. How stable VAD patients or adult congenital heart disease patients with declining symptoms should be prioritized for transplantation is unclear. Nevertheless we do need effective and simple models that can predict which of these disparate groups would benefit from transplantation so that we can fairly distribute this scarce commodity to the sickest patients that would benefit the most from transplantation.