Heart transplantation remains the definitive treatment for advanced heart failure, but continues to be constrained by a global shortage of suitable donor organs. In response, national heart transplant allocation systems have evolved to determine the prioritisation of recipients based on clinical urgency, anticipated outcomes and equity of access. This chapter provides an international comparative analysis of adult donor heart allocation frameworks, focusing on high-volume transplant systems including the United Kingdom, United States, France and Eurotransplant. It outlines the assessment of clinical urgency in advanced heart failure, including the role of inotropic dependence and mechanical circulatory support. Key differences in allocation methodologies are identified, determining clinical urgency and other important factors within the frameworks. The chapter further explores the ethical foundations of organ allocation, considering the application of distributive justice and equity in contemporary practice. Finally, the implications of allocation policy on waiting lists, transplant outcomes and system behaviours are discussed, together with future developments in donor heart distribution, including data-driven models and technological innovation. Insights from international allocation frameworks can guide clinicians and policymakers in developing fairer, evidence-based approaches to prioritising patients with advanced heart failure.