*Purpose: Describe and explain variations in listing practice among U.S. transplant centers in response to the new allocation policy.

*Methods: We performed an observational cohort study comparing adult, heart-alone transplant candidates listed post-policy (December 2018 – February 2020) to a seasonally matched, pre-policy cohort (December 2016 – February 2018). We used mixed-effect logistic regression models to estimate each transplant center’s expected and observed rate of high-priority status listing, and the association of pre-policy organ procurement organization (OPO) characteristics with the policy effect.

*Results: Similar numbers of candidates were listed by U.S. transplant centers (N = 96) in each policy period (4,472 vs. 4,498). The average transplant center had greater odds of utilizing high-priority status than expected (OR: 6.34; 95% CI: 5.08-7.91), after adjusting for candidate characteristics. Ninety-one of 96 (94.8%) centers listed significantly more candidates at high-priority status than expected, with the unexpected increase varying from 4.8% to 50.4% (IQR: 14.0% – 23.3%). Compared with the average center, centers in OPOs with high rate of transplantation among high-priority candidates under the previous allocation scheme were significantly more likely to list candidates at high-priority status under the new policy (OR: 9.73, p = 0.01).

*Conclusions: While listing behavior varied substantially between transplant centers in response to the new allocation policy, the utilization of high-priority statuses exceeded expectations in almost all centers. Widespread changes in transplant center practices may undermine the effectiveness of the new heart allocation policy.

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