As we approach the five-year anniversary of the 2018 heart allocation system in the United States, it is imperative to consider the changing landscape of mechanical circulatory support and the strategies used to bridge patients into heart transplants. This manuscript reviews the history of the heart allocation system, as well as the conditions that led to its multiple revisions. We discuss initial outcomes following the implementation of the new allocation system, including the impact on waitlist mortality and post-transplant outcomes. We also give special consideration to changes in bridging strategies using venoarterial extracorporeal membrane oxygenation (VA ECMO), intra-aortic balloon pumps, and durable left ventricular assist devices (LVADs).