*Purpose: On Oct 18, 2018, the heart allocation system changed to better risk stratify adult candidates, and a current project is underway to remove donation service area (DSA) from allocation rules. The Scientific Registry of Transplant Recipients used thoracic simulated allocation modeling (TSAM) to test outcomes by prior rules, new DSA-first rules, and proposed rules replacing DSA with 500 or 250 nautical miles (NM) as the first unit of allocation. We summarized the impact of these rules on children, by pediatric status.

*Methods: TSAM included all candidates, recipients, and donors, July 1, 2009-June 30, 2011, and simulated match-runs according to four sets of rules. In prior rules, status 1A children received the first offers of pediatric donor organs out to 500NM, but competed directly with all status 1A adults for adult donor organs, first locally, then out to 500NM. Under the other three rules we simulated, status 1A pediatric candidates receive higher allocation priority than they did under prior rules.

*Results: Overall transplant counts and rates were similar across the four simulations; within a status group, rates and counts among prior, DSA-first, and 250NM rules were similar. The 500NM rules resulted in higher rates and counts for status 1A children, lower rates for status 2 children, and similar counts and rates for status 1B children, compared with prior rules and new DSA-first rules. Waitlist mortality counts and rates were similar across four simulations, overall and by status.

*Conclusions: Pediatric candidates are unlikely to be disadvantaged by new heart allocation rules or future DSA-free rules due to their placement in allocation ordering. OPTN will monitor outcomes as data become available, and continue to consider the special needs of acutely ill children when choosing new future rules.

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