Heart transplant candidate assessment: Contemporary principles, multidimensional evaluation and implications for organ utilisation

Heart transplantation remains the definitive treatment for selected patients with advanced heart failure, yet appropriate identification and evaluation of candidates is increasingly complex. Contemporary practice requires integrating objective markers of cardiac disease severity with a holistic assessment of comorbidities, psychosocial readiness, and long-term capacity to benefit from transplantation. Modern guidelines—particularly the 2018 ESC Heart Failure Association position statement and the 2024 ISHLT candidate evaluation guidelines—have reshaped the conceptual framework for transplant candidacy, emphasising the interplay between disease severity, reversible and irreversible contraindications, frailty, and dynamic assessment over time. This review synthesises current principles guiding transplant evaluation and discusses how these decisions influence broader organ utilisation strategies. A narrative, clinically grounded approach highlights the importance of recognising patients who are sufficiently unwell from heart failure to derive benefit, yet not so compromised by end-organ failure or other high-risk features that transplantation becomes futile. Through a multidimensional model encompassing medical, functional, psychological, and social domains, modern transplant programmes aim to optimise individual outcomes while safeguarding equitable and efficient use of scarce donor organs.