Evidence map›Paper›PMID 41778948›Full record

ArticleJournal of the American College of Cardiology2026

Status Exceptions and Misalignment of Medical Urgency in U.S. Pediatric Heart Transplantation.

Daniel J Ahn, Antony Attia, Toshihiro Nakayama, Nikhil Narang, Kevin Daly, Kiran K Khush, William F Parker, Kazunari Sasaki

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PubMed Full text at PMC Publisher
In one paragraph

Article in Journal of the American College of Cardiology, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 1 paper.

0numbers the graph read from it
0cells of the map it votes in
1citing papers in PubMed
–field-weighted citation impact
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

1 citing paper in PubMed.

  1. Article
4 · The record

Corrections and comments

PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.

5 · Who and what money

Authors and funding

8 authors.

Daniel J AhnDepartment of Surgery, Stanford University, Stanford, California, USA; Stanford Transplant Outcomes Research Center, Stanford University, Stanford, California, USA; Stanford Cardiovascular Institute, Stanford University, Stanford, California, USA. Electronic address: djahn@stanford.edu.
Antony AttiaDepartment of Surgery, Stanford University, Stanford, California, USA; Stanford Transplant Outcomes Research Center, Stanford University, Stanford, California, USA.
Toshihiro NakayamaDepartment of Surgery, Stanford University, Stanford, California, USA; Stanford Transplant Outcomes Research Center, Stanford University, Stanford, California, USA.
Nikhil NarangDepartment of Medicine, University of Chicago, Chicago, Illinois, USA.
Kevin DalyDepartment of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.
Kiran K KhushStanford Cardiovascular Institute, Stanford University, Stanford, California, USA; Department of Medicine, Stanford University, Stanford, California, USA.
William F ParkerDepartment of Medicine, University of Chicago, Chicago, Illinois, USA; Department of Public Health Sciences, University of Chicago, Chicago, Illinois, USA; MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois, USA.
Kazunari SasakiDepartment of Surgery, Stanford University, Stanford, California, USA; Stanford Transplant Outcomes Research Center, Stanford University, Stanford, California, USA.

Funding

Stanford Integrated Cardiovascular/Pulmonary Residency Research Training ProgramR38HL143615 · NHLBI · STANFORD UNIVERSITY · PI Michael Peter Fischbein, Marlene Rabinovitch · 2020 to 2026
$2.2M
Improving the efficiency and equity of critical care allocation during a crisis with place-based disadvantage indicesR01LM014263 · NLM · UNIVERSITY OF CHICAGO · PI William F Parker · 2023 to 2026
$2.0M
NHLBI NIH HHS R38 HL143615NLM NIH HHS R01 LM014263
6 · The paper itself

Abstract

backgroundPediatric heart transplant candidates experience high waitlist mortality, in part because of limited availability of appropriate donor hearts. Transplant physicians can request status exceptions to increase priority for candidates, but this practice may contribute to overcrowding of high-priority statuses. In 2021, the National Heart Review Board (NHRB) was established to standardize exception review, but its impact remains unknown.

objectivesThe goal of this study was to determine whether exceptions are granted to children at high risk of death on the waitlist and the impact of the NHRB on outcomes.

methodsUsing Organ Procurement and Transplantation Network data, we identified all pediatric heart transplant candidates listed March 2016 through March 2025. We estimated the association between status exceptions and waitlist mortality using mixed-effects Cox proportional hazards models and compared concordance indices for the current system vs a hypothetical system without exceptions.

resultsAmong 6,026 candidates, 745 (12.4%) died or deteriorated and 1,668 (27.7%) received exceptions. Exception recipients had a significantly lower waitlist mortality risk than standard criteria patients (HR: 0.41; 95% CI: 0.31-0.55; P < 0.001) and the NHRB's impact on this association was nonsignificant (P = 0.62). We observed significant heterogeneity in waitlist mortality within status 1A, with exception recipients having the highest survival. When modeling waitlist mortality, the concordance index improved from 0.694 (95% CI: 0.682-0.706) with exceptions to 0.713 (95% CI: 0.700-0.724) without exceptions (P < 0.001).

conclusionsPediatric heart transplant candidates granted status exceptions have significantly lower medical urgency than those meeting standard criteria. Implementation of a national review board did not result in improved alignment between waitlist mortality and listing status.

Indexed as

Heart TransplantationPatient SelectionTissue and Organ ProcurementWaiting ListsAdolescentChildChild, PreschoolFemaleHumansInfantMaleUnited Statespediatric heart transplantationstatus exceptionswaitlist mortality

Identifiers

PMID41778948
PMCPMC13283330

What Socratic holds

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Registered trials

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Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the Socratic graph.