Background In the current UNOS heart transplant listing system, priority is given to patients who are on temporary mechanical circulatory support (tMCS), while those on durable left ventricular assist devise (LVAD) support are deemed stable and not prioritized for transplant. Outcomes have significantly improved with the HeartMate 3 (HM3) devices, but it is unclear whether older generation devices, the HeartMate II (HM II) or HeartWare (HVAD) have a survival disadvantage and should be prioritized. The aim of this study is to compare the composite outcome (waitlist mortality and incidence of delisting) between patients on with tMCS and durable LVAD, when compared to HM3. Methods All adult patients listed for heart transplantation on MCS after implementation of the new listing system were included in this analysis (10/2018-10/2021). Patients with RVAD, BiVAD, TAH and ECMO were excluded from this analysis. Survival analysis (Kaplan Meier curves and multivariable Cox regression) was used to compare the outcomes between groups. Furthermore, sensitivity analysis was performed using a propensity-score (PS) matching, comparing HM3 to all other device types, including covariates at the time of listing. Results A total of 12,568 patients were included in this analysis of which 1,877 were on tMCS and 2,692 were LVAD. Eighty percent (n=1,498) of the tMCS were supported with IABP, while the remainder with Impella. In the LVAD category, the vast majority, 82% (n=1,546) had HM3 while the remainder had HVAD [27% (n=730)] and HM II [15% (n=416)]. In the pre-matched cohort, the event rate was lower in the LVAD group compared to tMCS (8.7% v/s 33.7% p<0.001). HM3 had the best outcomes compared to all other device types (6.3%). In the PS-matching analysis, HM3 had a lower composite outcome when compared to tMCS (13.9% vs 27.5%, p=0.005) and HVAD/HM2 LVAD (7.0 vs 12.6%; p=0.003); HM3 vs HVAD (6.7% vs 10.0% p= 0.14) and HMII (5.7% vs 16.2; p=0.002). tMCS had significantly higher multivariable hazard ratio for outcome event than durable LVAD in the entire cohort (HR 8.64, p<0.001) and PS-matched cohort (HR 3.37, p<0.001). Other risk factors included listing status (1-3) (HR 3.43, p<0.01), creatinine (HR 1.43, p<0.01) and ventilation (HR 1.43, p<0.001) at the time of listing. Conclusion In this PS-matched analysis on all patients on MCS support, HM3 had the lowest risk of wait-list mortality or delisting due to medical deterioration. This risk was highest in tMCS compared to all durable LVAD groups, supporting an earlier transition to HM3 if prolonged wait time is anticipated. Patients on HM II and HVAD should be prioritized with a higher listing status as opposed to HM3. In the current UNOS heart transplant listing system, priority is given to patients who are on temporary mechanical circulatory support (tMCS), while those on durable left ventricular assist devise (LVAD) support are deemed stable and not prioritized for transplant. Outcomes have significantly improved with the HeartMate 3 (HM3) devices, but it is unclear whether older generation devices, the HeartMate II (HM II) or HeartWare (HVAD) have a survival disadvantage and should be prioritized. The aim of this study is to compare the composite outcome (waitlist mortality and incidence of delisting) between patients on with tMCS and durable LVAD, when compared to HM3. All adult patients listed for heart transplantation on MCS after implementation of the new listing system were included in this analysis (10/2018-10/2021). Patients with RVAD, BiVAD, TAH and ECMO were excluded from this analysis. Survival analysis (Kaplan Meier curves and multivariable Cox regression) was used to compare the outcomes between groups. Furthermore, sensitivity analysis was performed using a propensity-score (PS) matching, comparing HM3 to all other device types, including covariates at the time of listing. A total of 12,568 patients were included in this analysis of which 1,877 were on tMCS and 2,692 were LVAD. Eighty percent (n=1,498) of the tMCS were supported with IABP, while the remainder with Impella. In the LVAD category, the vast majority, 82% (n=1,546) had HM3 while the remainder had HVAD [27% (n=730)] and HM II [15% (n=416)]. In the pre-matched cohort, the event rate was lower in the LVAD group compared to tMCS (8.7% v/s 33.7% p<0.001). HM3 had the best outcomes compared to all other device types (6.3%). In the PS-matching analysis, HM3 had a lower composite outcome when compared to tMCS (13.9% vs 27.5%, p=0.005) and HVAD/HM2 LVAD (7.0 vs 12.6%; p=0.003); HM3 vs HVAD (6.7% vs 10.0% p= 0.14) and HMII (5.7% vs 16.2; p=0.002). tMCS had significantly higher multivariable hazard ratio for outcome event than durable LVAD in the entire cohort (HR 8.64, p<0.001) and PS-matched cohort (HR 3.37, p<0.001). Other risk factors included listing status (1-3) (HR 3.43, p<0.01), creatinine (HR 1.43, p<0.01) and ventilation (HR 1.43, p<0.001) at the time of listing. In this PS-matched analysis on all patients on MCS support, HM3 had the lowest risk of wait-list mortality or delisting due to medical deterioration. This risk was highest in tMCS compared to all durable LVAD groups, supporting an earlier transition to HM3 if prolonged wait time is anticipated. Patients on HM II and HVAD should be prioritized with a higher listing status as opposed to HM3.