Background:One of the goals of the revised 6-tiered US adult heart allocation policy was to improve risk stratification of patients to lower exception status utilization for transplant listing. We sought to define the characteristics and outcomes of waitlisted patients using exception status and to examine region- and center-level differences in utilization of exception status in the new heart allocation system.Methods:This retrospective cohort analysis of the United Network for Organ Sharing database included adult waitlisted patients for heart transplant between October 18, 2018, and June 30, 2020, in the United States, stratified by use of exception status versus standard criteria.Results:Out of 6351 patients, 1907 (30.0%) were waitlisted under exception status. Patients using exception status were more likely to have a nonischemic cause of heart failure, blood type O, United Network for Organ Sharing status 2 at listing and were less likely to have a durable left ventricular assist device at listing. Exception status utilization varied significantly between and within United Network for Organ Sharing regions. Listing by exception criteria was associated with a significantly higher incidence of heart transplantation compared with listing by standard criteria (hazard ratio, 1.25 [1.15–1.38], P<0.001), without increased risk of death or delisting for worsening clinical status (hazard ratio, 0.83 [0.65–1.05], P=0.12) after multivariable adjustment.Conclusions:The status tiers of the new heart allocation system may not fully capture medical urgency and complexity of waitlisted patients as assessed by transplant physicians and review committees and may limit the ability to develop a heart allocation score.

中文翻译：

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新成人心脏分配系统中的异常状态列表：旧问题的新解决方案？

背景：修订后的 6 级美国成人心脏分配政策的目标之一是改善患者的风险分层，以降低移植列表的异常状态利用率。我们试图使用异常状态定义候补患者的特征和结果，并检查新心脏分配系统中异常状态利用的区域和中心级别差异。方法：对器官共享联合网络数据库的回顾性队列分析包括 2018 年 10 月 18 日至 2020 年 6 月 30 日期间在美国接受心脏移植的成年候补患者，通过使用例外状态与标准标准进行分层。结果：在 6351 名患者中，1907 名 (30.0%) 被列入例外名单地位。使用异常状态的患者在上市时更有可能患有心力衰竭、O 型血、器官共享联合网络状态 2 的非缺血性原因，并且在上市时不太可能拥有耐用的左心室辅助装置。器官共享联合网络区域之间和内部的异常状态利用率差异很大。与按标准列出相比，按例外标准列出的心脏移植发生率显着升高（风险比，1.25 [1.15–1.38]，P <0.001），在多变量调整后没有增加死亡或因临床状态恶化而退市的风险（风险比，0.83 [0.65–1.05]，P = 0.12）。结论：新心脏分配系统的状态等级可能无法完全捕捉由移植医师和审查委员会评估的候补患者的医疗紧迫性和复杂性，并可能限制制定心脏分配评分的能力。