Exception Status Listing in the New Adult Heart Allocation System: A New Solution to an Old Problem?

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Veli K Topkara1, Kevin J Clerkin1, Justin A Fried1

  • 1Division of Cardiology, Department of Medicine (V.K.T., K.J.C., J.A.F., J.G., J.R., S.H.L., F.L., M.H., M.A.F., G.S., N.U.), Columbia University Irving Medical Center, New York, NY.

Circulation. Heart Failure
|May 28, 2021
PubMed

Insights

The revised US heart transplant policy aimed to reduce exception status use. Exception status listing increased transplant rates without raising mortality risk, suggesting it captures patient complexity not fully addressed by standard criteria.

Area of Science:

  • Cardiology
  • Transplantation Medicine
  • Health Policy

Background:

  • The revised 6-tiered US adult heart allocation policy aimed to improve risk stratification and reduce exception status utilization for transplant listing.
  • This study defines characteristics and outcomes of waitlisted patients using exception status and examines regional/center differences in its utilization.

Purpose of the Study:

  • To evaluate the utilization and impact of exception status in the new US adult heart allocation system.
  • To compare outcomes of patients listed under exception status versus standard criteria.

Main Methods:

  • Retrospective cohort analysis of the United Network for Organ Sharing database.
  • Included adult heart transplant waitlisted patients in the US from October 2018 to June 2020.
  • Stratified patients by exception status versus standard criteria listing.

Main Results:

  • 30% of 6351 patients were listed under exception status.
  • Exception status patients were more likely to have nonischemic heart failure, blood type O, and were less likely to have a left ventricular assist device.
  • Exception listing was associated with higher transplant incidence (HR 1.25) without increased mortality risk (HR 0.83).

Conclusions:

  • The new heart allocation system's tiers may not fully capture patient medical urgency and complexity.
  • Physician and committee assessments suggest limitations in the current system's ability to stratify all waitlisted patients effectively.
Abstract

Keywords:
deathguidelineheart failureheart transplantationmortality

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