This article aims to shed light on the major implications of the new allocation system by discussing the observed outcomes and complications and suggesting a few steps to prevent and manage those potential challenges.

The new allocation system implemented in 2018 aimed to prioritize high-risk patients and provide a better equitable opportunity for heart transplantation. However, despite the success in reducing wait-list mortality, this change brought up many direct and indirect challenges to patient care, such as worsening ischemic time and an increase in the use of temporary mechanical support at the expense of durable LVADs. Moreover, the parallel advancement in LVAD technology and the associated improvement in patient outcomes added another layer to the complexity of shared decision-making in the advanced heart failure population.

LVAD patient population is expected to continue to expand. This growth will also be accompanied by longer wait-time and a higher prevalence of LVAD complications. Advanced technologies such as wireless devices and remote monitoring are quite promising in that regard. Also, advanced artificial intelligence algorithms might help to improve patient selection, ameliorate early detection of complications, and offer further guidance to manage those complications.