Urgent listing exceptions and outcomes in pediatric heart transplantation: Comparison to standard criteria patients

Background United Network for Organ Sharing (UNOS) policy enables listing exceptions to avoid penalizing patients with waitlist mortality not captured by standard criteria. Outcomes among patients listed by exception have not been analyzed. Methods We performed a retrospective analysis of pediatric (≤17 years of age, n = 4,706) listings (2006 to 2015) for primary, isolated heart transplantation within the UNOS data set, assessing Status 1A exception (n = 211, 4.5%) use across regions and patient characteristics and evaluating waitlist outcomes compared with candidates listed using standard criteria. Results Death or removal for reason other than transplant did not differ between exception and standard criteria patients at 1 month (11.7% vs 16.2%, p = not statistically significant [NS]), 2 months (18.2% vs 29.0%, p = 0.11) or overall (16.1% vs 22.0%, p = NS) on the waitlist. Rates were higher than among Status 1B patients (1 month: 2.8%; 2 months: 5.6%; overall: 14.9%; p < 0.0001). The cumulative incidence of competing risks (transplantation, death/removal for reasons other than transplant and removal) did not differ when comparing Status 1A exception patients with Status 1A standard criteria patients. Use of 1A exceptions varied across UNOS regions (1.9% to 22.3%, p < 0.0001). Risk-adjusted modeling identified patients more (hypertrophic cardiomyopathy: odds ratio [OR] = 2.8, 95% confidence interval [CI] 1.5 to 5.0; restrictive cardiomyopathy: OR = 2.7, 95% CI 1.7 to 4.3) and less (low socioeconomic status: OR = 0.7, 95% CI 0.5 to 1.0) likely to use an exception. Use of exceptions was uncorrelated with regional outcomes. Conclusions Waitlist mortality among Status 1A exception patients is similar to that among those listed by standard criteria. However, variation in exception use across geography and demography may contribute to inequities in access to transplantation, particularly for those with low socioeconomic status. Standardization of practices may decrease regional variation and minimize inequities.