Status One and Status Two Exception Use in the Updated Heart Allocation System

Beginning in 2005, the United States heart allocation system grouped high-urgency transplant candidates into a single status. This 3-tier system led to overcrowding in the highest-urgency status category, including prolonged waiting times and concerns about inequities in allocation. 1 Chouairi FC Fuery M Clark KA Mullan CW Stewart J Caraballo C et al. Evaluation of racial and ethnic disparities in cardiac transplantation. J Am Heart Assoc. 2021; 10e021067 Crossref Scopus (18) Google Scholar The revised 7-tiered U.S. heart-allocation policy implemented in October 2018 aimed to improve risk stratification to better facilitate geographic sharing of organs and improve patients’ outcomes. 2 Davies RR Farr M Silvestry S Callahan LR Edwards L Meyer DM et al. The new United States heart allocation policy: progress through collaborative revision. J Heart Lung Transplant. 2017; 36: 595-596 Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar An expected byproduct of improved differentiation among the urgencies of various transplant candidates is that fewer exception requests would be necessary secondary to the increased categorical nature built into the new hierarchical system. However, early reports of the new system demonstrate that, contrary to intention, status exceptions have since increased from 57 (3.5%) candidates in the 10-month prepolicy cohort to 241 (15%) candidates in the 10-month postpolicy cohort 3 Parker WF Chung K Anderson AS Siegler M Huang ES Churpek MM. Practice changes at U.S. transplant centers after the new adult heart allocation policy. J Am Coll Cardiol. 2020; 75: 2906-2916 Crossref PubMed Scopus (63) Google Scholar ; overall, 30% of patients in the new allocation system were listed with exceptions. 4 Topkara VK Clerkin KJ Fried JA Griffin J Raikhelkar J Hi Lee S et al. Exception status listing in the new adult heart allocation system: a new solution to an old problem?. Circulation: Heart Fail. 2021; 14e007916 Crossref PubMed Scopus (9) Google Scholar The general characteristics of all heart transplant patients listed as exceptions have been investigated, but the analyses of these patients have not been stratified by status. 4 Topkara VK Clerkin KJ Fried JA Griffin J Raikhelkar J Hi Lee S et al. Exception status listing in the new adult heart allocation system: a new solution to an old problem?. Circulation: Heart Fail. 2021; 14e007916 Crossref PubMed Scopus (9) Google Scholar We aimed to report the characteristics of patients listed for heart transplant as Status One or Two, by exception, in the new allocation system.