*Purpose: Multiple pre-transplant scores aimed at stratifying the risk of death or allograft loss after heart transplantation have been developed over time but their use in clinical practice remains limited. The development of a heart allocation score has become the next priority following the recent revision of the UNOS heart allocation system. We aimed to evaluate the discrimination of all existing pre-transplant risk scores in a contemporary UNOS cohort.

*Methods: We applied 13 different scoring systems developed between 1999 and 2019 to a contemporary UNOS cohort of heart transplant recipients. We selected first non-combined adult heart transplantations performed between January 1st, 2013 to December 31st, 2017. The primary endpoint was all-cause mortality or retransplantation during the first-year post-transplant. The discrimination of the score was evaluated by the area under the ROC-curve. Subgroups analyzes were drawn according to the ventricular assist devices (VAD) status at transplant.

*Results: The overall validation cohort included 11,578 patients (5,822 and 5,752 patients with or without VAD, respectively; 4 missing values). Recipients were mostly males (74%) and mean age was 52.9±13.5. The discriminative performance of all scores was poor, ranging from 0.548 to 0.662 (median = 0.604) in the overall cohort and from 0.537 to 0.644 (median = 0.602) and 0.549 to 0.654 (median = 0.604) in patients with and without VAD at transplant, respectively (Figure, dash line = median).

*Conclusions: In a contemporary cohort, none of the 13 post-transplant prognosis scores were shown to accurately stratify the risk of early death or retransplantation after HTx. Our findings raise concerns concerning the use of the currently available prognosis scores in the clinical field and emphasize the need for a robust and reliable score.

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