Variability in Status 1 Exception Practices and Candidate Outcomes After the 2018 U.S. Heart Allocation Changes
Recommended Citation
Narang N, Cascino TM, Cowger JA, Kanwar MK, Masotti M, and Cogswell R. Variability in Status 1 Exception Practices and Candidate Outcomes After the 2018 U.S. Heart Allocation Changes. J Card Fail 2026.
Document Type
Article
Publication Date
2-2-2026
Publication Title
Journal of cardiac failure
Keywords
Heart Transplant; Resource Allocation; VA-ECMO
Abstract
BACKGROUND: Status 1 listings represents the highest priority for heart transplantation (HT) and is intended for candidates with the greatest medical urgency (i.e. VA-ECMO).
OBJECTIVES: The study aims to assess the longitudinal changes in Status 1 listings, center-level listing variations, and implications on outcomes with or without an exception post-2018 allocation change.
METHODS: We analyzed de-identified OPTN data for adult first-time, single-organ HT candidates listed Status 1 between October 18, 2018-July 1, 2024 (n=2,123). Trends in overall and exception (1E) listings were evaluated by time, region, and center size. Fine-Gray sub distribution hazards regression were used to compare 30-day transplant and delisting for death/deterioration by exception status, and to identify characteristics associated with adverse outcomes.
RESULTS: Between 2018- 2024, Status 1 listings doubled from 7.1% to 14.4%, driven by a rise in 1E use (2.3% to 9.8%), which in 2024 comprised >50% of Status 1 listings. Use of exceptions varied widely by center and region. 1E candidates had similar 30-day transplant rates (sHR 0.97, 95% CI 0.88-1.07, P=0.5) but lower risk of delisting for death/deterioration compared with Status 1 candidates (sHR 0.69, 95% CI 0.48-0.98, P=0.041). In contrast, Status 1 candidates with blood group O or PRA ≥30% had lower rates of HT and higher rate of delisting for death/deterioration.
CONCLUSION: Status 1 listings have increased substantially since 2018, driven by rising 1E use that varies widely across centers. Candidates listed with Status 1E appear less ill, while patients with disadvantages (blood group O and sensitization) remain at high risk for adverse outcomes.
PubMed ID
41638620
ePublication
ePub ahead of print
