*Purpose: In October 2018, a new heart allocation policy was introduced that expanded the number of listing statuses and established a national review board, abolishing regional review of exception and extension requests. We sought to determine whether the goal of reducing exception requests has been achieved.

*Methods: Using the Scientific Registry of Transplant Recipients database, we evaluated the impact of the new heart allocation policy on exception and extension requests by status. We included adult heart transplant candidates waitlisted February 1, 2016 to June 30, 2021, excluding October 2018. The study period was divided equally: pre-policy (Feb. 2016 to Sept. 2018) and post-policy (Nov. 2018 to June 2021).

*Results: Pre-policy, 10,374 candidates were listed for transplant, and 10,799 were listed post-policy. Pre-policy, 179 (1.7%) candidates were listed by exception compared with 1,490 (13.8%) post-policy. Of those listed pre-policy, 5,814 received transplants; 416 (7.2%) by exception and 1,950 (33.5%) after extension of their status, including exception status. Of those listed post-policy, 6,907 received transplants; 2,336 (33.8%) were by exception, constituting a 4.6-fold increase, and 1,499 (21.7%) by extension. The largest number of exceptions was in status 2 listings, with 21.6% of candidates transplanted as status 2 exception (Table). At the highest statuses, of candidates transplanted status 1A pre-policy, 10.4% were by exception. Of candidates transplanted statuses 1 to 3 post-policy, 38.5% were by exception.

*Conclusions: Under the new policy, there has been a marked increase in patients transplanted by exception, driven by status 2 transplants, thus defeating the policy’s goal of reducing exception requests.

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