*Purpose: The new heart allocation policy (October 2018) expanded the number of listing statuses and established a national review board for exception requests in an effort to reduce these requests. We examined whether the new policy has achieved this goal and improved survival among higher-urgency statuses.

*Methods: Using the Scientific Registry of Transplant Recipients database, we assessed the number of patients listed by exception and performed unadjusted Kaplan-Meier survival analyses to determine the impact of listing by exception on 1-year post-transplant survival pre- and post-policy change. We included adult heart transplant recipients waitlisted and transplanted from February 1, 2016, to June 30, 2020, excluding October 2018. The study period was divided into 2 20-month periods: pre-policy (02/2016 to 09/2017) and post-policy (11/2018 to 06/2020).

*Results: Pre-policy, 3133 candidates were listed and transplanted, of whom 204 (6.5%) were by status 1A exception. Post-policy, 3790 candidates were listed and transplanted, of whom 1210 (31.9%) were by exception at statuses 1 to 4. Overall, there were no differences in 1-year post-transplant survival by status pre-policy (p=0.40) or post-policy (p=0.05) change. However, pre-policy 1-year survival was significantly lower for candidates transplanted by exception compared with those transplanted using standard criteria (p=0.03) (Table 1). Post-policy, 1-year survival was similar for candidates transplanted by exception compared with those transplanted using standard criteria, except for those transplanted at status 4 by exception, who had significantly better 1-year survival than those transplanted using standard criteria (p=0.03) (Table 1).

*Conclusions: Despite expansion of listing statuses, post-policy transplants by exception increased significantly, demonstrating that the goals of the new policy have not been met. Candidates transplanted status 4 exception had significantly better 1-year survival and may differ in important ways from the larger pool of status 4 candidates. Institution of a national review board may have inadvertently contributed to an increase in transplants by exception.

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