Waitlist mortality risk (US-CRS score) distribution among status 1 and 2 adult heart transplant candidates with exceptions.

Authors

Najiya Fatma, Suhani S Patel, Grace R Lyden, Nader Moazami, Brian Wayda, William F Parker, Sommer E Gentry

Published in

JHLT open. Volume 14. Pages 100706. Epub Oct 12, 2026.

Abstract

The US-candidate risk score (US-CRS) predicts waitlist mortality among heart transplant candidates using 7 laboratory, cardiovascular, and cardiac device usage variables on a 50-point scale, with higher scores indicating greater mortality risk. We assessed whether US-CRS accurately assigns mortality risk for exception candidates, and whether the alignment of allocation priority with waitlist mortality risk (US-CRS) differs between candidates with and without exceptions.
We compared the performance of US-CRS in candidates with and without exceptions using receiver operating curves. We compared US-CRS distributions using the Kolmogorov-Smirnov (KS) test and examined the proportion of candidates below specific score thresholds in each group. We also compared candidates with and without exceptions using Wilcoxon Rank-Sum test for continuous variables and Pearson's Chi-squared test or Fisher exact test for categorical variables.
US-CRS is accurate for measuring mortality risk among exception candidates as it is among non-exception candidates. Patients with higher waitlist status had higher median US-CRS. However, the median US-CRS of Status 1 candidates without exceptions (50 [IQR 48-50]) was significantly higher than for candidates with exceptions (45 [36-48]; [ $p\le 0.05$ ]), and similarly for Status 2 (46 [41-49] vs. 42 [32-47]; [ $p\le 0.05$ ]). Notably, 33.13% of Status 1 and 41.28% of Status 2 candidates with exceptions had US-CRS below 40, compared to only 1.84% and 19.20% of candidates without exceptions, respectively. Conversely, among candidates in Status 3 and 4, candidates with exceptions generally had higher US-CRS than candidates without exceptions.
Allocation priority under the status system does not align with estimated mortality risk; misalignment is greater for candidates with exceptions. While some exception candidates in Status 1 and 2 do have high estimated mortality risk and legitimately need exceptions, many of these exceptions appear to have been granted to candidates with relatively low medical urgency.

PMID:
42999889
Bibliographic data and abstract were imported from PubMed on 08 Nov 2026.

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