OPTN/SRTR 2021 Annual Data Report: Heart

Monica M. Colvin^1,2, Jodi M. Smith^1,3, Yoon Son Ahn¹, Eric Messick⁴, Kelsi Lindblad⁴, Ajay K. Israni^1,5,6, Jon J. Snyder^1,5,6, Bertram L. Kasiske^1,6

¹Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN

²Department of Cardiology, University of Michigan, Ann Arbor, MI

³Department of Pediatrics, University of Washington, Seattle, WA

⁴Organ Procurement and Transplantation Network, United Network for Organ Sharing, Richmond, VA

⁵Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN

⁶Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, MN

Abstract

The past 5 years have posed challenges to the field of heart transplantation. The 2018 heart allocation policy revision was accompanied by anticipated practice adjustments and increased use of short-term circulatory support, changes that may ultimately serve to advance the field. The COVID-19 pandemic also had an impact on heart transplantation. While the number of heart transplants in the United States continued to increase, the number of new candidates decreased slightly during the pandemic. There were slightly more deaths following removal from the waiting list for reasons other than transplant during 2020, and a decline in transplants among candidates listed as status 1, 2, or 3 compared with the other statuses. Heart transplant rates decreased among pediatric candidates, most notably among those younger than 1 year. Despite this, pretransplant mortality has declined for both pediatric and adult candidates, particularly candidates younger than 1 year. Transplant rates have increased in adults. The prevalence of ventricular assist device use has increased among pediatric heart transplant recipients, while the prevalence of short-term mechanical circulatory support, particularly intra-aortic balloon pump and extracorporeal membrane oxygenation, has increased among adult recipients.

Keywords: Allocation, donor, heart failure, heart transplant, left ventricular assist device, mechanical circulatory support, outcomes

1 INTRODUCTION

Heart transplantation continues to provide selected patients with advanced heart failure substantially better quality of life and survival than left ventricular assist devices, the only other viable therapy for patients with stage D heart failure. Donor availability, disparities in access, and optimal risk stratification remain challenges. As we enter the fifth year of the 2018 Organ Procurement and Transplantation Network (OPTN) heart allocation policy, it is apparent that heart allocation practices have shifted toward the use of short-term mechanical circulatory support, the most expeditious route for heart transplant. The Annual Data Report provides an evaluation of trends in US adult and pediatric heart transplant waiting lists, donation, transplants, and outcomes. Although data following the policy change are available, inherent differences in calculations during 2018 should be considered when assessing rates and other data obtained during that year (ie, data for 2018 should be interpreted with caution). An additional consideration is that when the new policy took effect on October 18, 2018, new statuses were assigned to candidates who remained on the waiting list. Because these candidates were only counted under the newly assigned statuses, the number of candidates who were awaiting transplant under the prior statuses (1A, 1B, or 2) may be lower or greater than expected in 2018.

2 ADULT HEART TRANSPLANT

2.1 Waiting List

Despite successful medical therapies for heart failure, the number of new heart transplant candidates continues to grow. The COVID-19 pandemic had a small impact on new listings. Following a plateau in 2018 through 2020, with a slight decrease in 2020 (from 4,087 in 2019 to 4,000 in 2020), the number of new listings increased to 4,373 in 2021, the largest increase in the past decade (Figure HR 1). The number of candidates prevalent on the list increased 32.3% from 2010 through 2016, peaking at 7,684 candidates, then declined from 2018 through 2020, likely due to higher transplant rates and fewer listings during the COVID-19 pandemic (Figure HR 2). Although the largest age group on the waiting list in 2021 was 50-64 years, there has been a gradual decrease in this age group since 2010. Candidates aged 65 years or older made up 20.4% of the list in 2021, an increase from 16.5% in 2010. Trends among other age groups have been stable since 2016 (Figure HR 3). Sex distribution remains relatively constant, with women constituting 24.9% in 2021 (Figure HR 4). There has been an increasing prevalence of non-White candidates. White candidates decreased from 69.4% in 2010 to 57.9% in 2021, while Black candidates increased from 20.4% to 27.4% and Hispanic candidates (includes candidates who are categorized as White and Hispanic or solely Hispanic) increased from 7.0% to 10.1%. Asian candidates have similarly increased, making up 3.6% of candidates in 2021 (Figure HR 5).

Coronary artery disease has become a less common primary diagnosis for heart transplant, and cardiomyopathy remains the most common diagnosis for heart transplant. In 2021, only 28.6% of all candidates, compared with 38.2% in 2010, were listed for coronary artery disease. Despite a change in allocation policy that provides a status for candidates with congenital heart disease, listings for congenital heart disease were infrequent, 4.7% in 2021, and overall stable since 2010. Listings for valvular heart disease are rare, 1.1% in 2021 (Figure HR 6).

Prior to the new policy, the proportion of candidates who were listed as status 2 declined from 2010 through 2017, whereas that of candidates listed as status 1A continued to gradually increase and candidates listed as status 1B reached a plateau (Figure HR 8). Following implementation of the new policy, most candidates were listed as status 4 (28.9% in 2021), followed by status 2 (24.7% in 2021). A major concern regarding the policy change was the potential increase in patients with extracorporeal membrane oxygenation (ECMO), and subsequently in status 1 listings. As anticipated, status 1 listings have increased since 2019; 5.5% of candidates were awaiting transplant as status 1 in 2021 (Figure HR 9). It is anticipated that this trend will continue.

While the age and sex of the typical heart transplant candidate in 2021 have not changed compared with 2011, there are substantially more Black and Hispanic candidates (Table HR 1), fewer with coronary artery disease, more with ventricular assist devices (VADs) (Table HR 2), and fewer who reside 150 miles or farther from the transplant center (Table HR 1).

2.2 Transplant Rates

Overall transplant rates were stable until 2016, after which there was a steady increase to 106.2 transplants per 100 patient-years in 2021, the highest rate this past decade (Figure HR 13). A similar trend was seen among all groups (excluding statuses), with the greatest 10-year increases occurring in candidates with the following attributes: aged 65 years or older, White, congenital heart disease, blood type B, female, and height of 150-<160 cm. Overall transplant rates increased 37.7% since 2017; however, marked increases (49.2% or greater) occurred among candidates aged 65 years or older, who are Asian or Hispanic, who have congenital heart disease or coronary artery disease, with blood type AB or B, and who are 150-<160 cm tall. Candidates in metropolitan and non-metropolitan areas have had similar transplant rates. Candidates aged 35-49 years, 180 cm or taller, Black candidates, those with congenital heart disease, and those of blood type O undergo transplant at substantially lower rates than others in their categories. Candidates with congenital heart disease continue to undergo transplant markedly slower than those with other diagnoses, 80.6 transplants per 100 patient-years, and slower than all other subgroups assessed in this report except blood group O, 72.7 transplants per 100 patient-years (Figures HR 14, 15, 16, 17, 18, 21, and 22).

It was anticipated that under the revised policy, transplant rates would increase, particularly among the highest-urgency candidates. Rates calculated during 2018 must be interpreted with caution due to variations created by relisting under new statuses and variations in exposure times for all statuses compared with 2017 and 2019. For this reason, 2018 will be excluded in this evaluation, although the data are available in the supporting information file (F19 and F20 tabs). Prior to the policy change, transplant rates among status 1A and 1B candidates reached a nadir of 212 and 66 transplants per 100 patient-years, respectively, in 2014, after which rates began to increase again. Status 2 transplant rates steadily declined until 2015 (Figure HR 19). Among the new status categories, transplant rates have fluctuated since 2019. As anticipated, the highest-urgency candidates undergo transplant the fastest: in 2021, status 1 candidates underwent transplant at a rate of 1,491.6 transplants per 100 patient-years; status 2, 1,069.7 per 100 patient-years; and status 3, 253.2 per 100 patient-years. Status 4 candidates have a much slower rate of transplant (73.3 transplants per 100 patient-years) followed by statuses 6 and 5 (62.9 and 49.6 transplants per 100 patient-years, respectively). A small proportion of adult patients were assigned to the pediatric listing statuses after October 18, 2018 (Figure HR 20). The transplant rates of these candidates fluctuated following the policy change.

Among adults listed for heart transplant during 2016-2018, 56.2% had undergone transplant by 1 year, 27.8% were still waiting, 5.0% died, and 11.0% had been removed. By 3 years, 66.7% had undergone transplant, 7.8% were still waiting, 6.3% died, and 19.2% had been removed (Figure HR 23). Candidates who underwent transplant within 3 months, 6 months, and 1 year of listing have increased since 2010 after reaching a nadir in 2014. There was a marked increase following the policy change, and, in 2020, 54% of candidates underwent transplant within 3 months of listing. Still, close to 30% of candidates have not undergone transplant by years 5 and 10 (Figure HR 24). The number of patients remaining on the waiting list at end of year has decreased from 2019 through 2021, despite increasing numbers being added because of an increase in donors and subsequently increased transplant rates (Table HR 4). More patients were removed for transplant or death in 2021 compared with 2019, and fewer were removed due to being too ill for transplant (Table HR 5).

2.3 Pretransplant Mortality

Following a plateau in 2010-2015, the overall pretransplant mortality rate declined 39.4% from 14.2 deaths per 100 patient-years in 2015 to 8.5 deaths per 100 patient-years in 2019 (Figure HR 25). Since then, the pretransplant mortality rate has been stable and was 8.6 deaths per 100 patient-years in 2021. There was a downward trajectory for all ages, races and ethnicities, sexes, and residential settings (metropolitan vs non-metropolitan). Candidates whose race was categorized as other had wide fluctuations in pretransplant mortality, with a peak of 40.9 deaths per 100 patient-years in 2017; however, this may be a spurious value and due to a small sample size (Figure HR 27). Candidates aged 18-34 years had a large decline in pretransplant mortality and now have the lowest mortality rate of all age groups: 6.5 deaths per 100 patient-years in 2021. Pretransplant mortality in candidates aged 65 years or older has declined but remains slightly higher than in other age groups: 11.1 deaths per 100 patient-years in 2021 (Figure HR 26). Among the diagnoses, there were wide fluctuations in pretransplant mortality among candidates with congenital heart disease and valvular heart disease. Valvular heart disease and other (as diagnosis) tend to have higher pretransplant mortality relative to other diagnoses. Despite having the lowest transplant rate of the diagnosis groups, patients with congenital heart disease also tend to have the lowest pretransplant mortality (Figure HR 29). Although pretransplant rates have been similar between candidates residing in metropolitan and non-metropolitan areas, since 2017 pretransplant mortality has trended slightly higher among candidates who reside in non-metropolitan areas (Figure HR 30).

Due to the aforementioned characteristics of rate calculations by status in 2018, the year 2018 will be excluded from this assessment of pretransplant mortality trends by status even though it is shown in the graphs (Figures HR 31 and 32). The pretransplant mortality of temporarily inactive candidates gradually declined since 2015. Among active candidates, those listed at the highest-urgency status tend to have the highest pretransplant mortality, both before and after the updated heart allocation policy. Under the prior policy, there was substantial decline in pretransplant mortality from 2010 through 2017 for status 1A and 1B candidates: 59.2% and 56.2%, respectively. There was little change in pretransplant mortality for candidates listed as status 2 under the prior system (Figure HR 31). Under the new system, candidates listed as status 1 have a markedly higher pretransplant mortality rate compared with other statuses; following a peak of 127.3 deaths per 100 patient-years in 2020 (excluding 2018), pretransplant mortality for status 1 candidates declined to 70.7 deaths per 100 patient-years in 2021. A similar trend was seen among status 2 candidates: 43.7 deaths per 100 patient-years in 2021. Candidates listed as status 3 had the third highest pretransplant mortality (among active listings): 17.4 deaths per 100 patient-years in 2021 (Figure HR 32). Despite broader sharing under the new heart allocation policy, there remains wide geographic variability in pretransplant mortality. Two donation service areas (DSAs) had pretransplant mortality of 0 and one DSA had a pretransplant mortality of 46.2 in 2021. Variability in pretransplant mortality rates may reflect center-specific practices and differences in patient selection, in addition to geographic variability in access (Figure HR 33).

The percentage of candidates who died within 6 months of removal from the waiting list for reasons other than transplant or death has declined from 27.9% in 2010 to 12.5% in 2021 (Figure HR 34). The trend persisted across age groups, although there was a slight increase over the past 5 years for the oldest age group (65 years or older). Candidates aged 50-64 years had a marked decline compared with other age groups, despite having had the highest mortality after removal for several years. Candidates aged 50-64 years have a comparable distribution of mortality to candidates aged 18-34 years (Figure HR 35). Prior to the policy change, there was a clear decline in mortality within 6 months of removal from the waiting list for reasons other than transplant or death; however, trends are less clear among the new statuses. Since 2019, there appears to have been an increase in mortality after removal for candidates listed as statuses 1, 2, or 6 and no change to a slight decrease for statuses 3 and 5, although, if we compare with 2018, there was a decline in mortality for all statuses except status 6. There was a noticeable decline in mortality for status 4 candidates, from 16.2% in 2019 to 5.3% in 2021. More time is required to fully assess trends in mortality after removal (Figure HR 36).

2.4 Donation

Despite the pandemic, the number of donors from whom a heart was recovered continued to increase, especially among the age groups 18-29 and 30-39 years. In 2021, 3,901 hearts were recovered for transplant (Figure HR 37). Most donors continue to be aged 18-29 years (35.1%) and 30-39 years (29.8%) (Figure HR 38). Pediatric donors and donors aged 55 years or older declined to a nadir of 13.4% and 1.8%, respectively (Figure HR 39). There are slightly fewer female donors compared with 2010; racial and ethnic distribution remains unchanged (Figures HR 40 and 41). Hearts recovered for transplant from donors who died from anoxia has steadily increased over the past decade, with no change between 2020 and 2021. Death from anoxia is the most common cause of death for donors, 45.0% in 2021, followed by head trauma, 40.8% (Figure HR 42).

The proportion of hearts recovered for transplant but not transplanted remains low, and in 2021, the rate of nonuse was 1.02% (Figure HR 43). There were similar trends seen by age, sex, race, hypertension status, body mass index (BMI), donor cause of death, and donor risk, with an overall increase over the past decade (Figures HR 44, 46, 47, 48, 49, and 50). In 2021, all hearts from Asian and pediatric donors were used. Nonuse was highest among donors with the following attributes: aged 30-39 years (1.7%), male (1.2%), hypertension (1.9%), BMI 40 kg/m² or greater (4.3%), cerebrovascular accident/stroke (1.7%), or other/unknown cause of death (2.3%) (Figures HR 44, 45, 46, 47, 48, and 49). Hearts from donors with hypertension were not used at twice the rate of those from donors without hypertension. Despite the trends among heart donors, rates of nonuse are extremely low compared with other organ groups.

2.5 Transplants

The upward trajectory in the number of heart transplants continued despite the COVID-19 pandemic. Heart transplants increased 67.4% from 2010 to 2021 (Figure HR 51). Increases were seen across all ages, sexes, races and ethnicities, and causes of heart failure except valvular heart disease, which declined to 22 transplants in 2021 (Figure HR 55). Notably, recipients aged 65 years or older increased 127.0%, from 322 in 2010 to 731 in 2021 (Figure HR 52). From 2010 to 2021, the numbers of Asian and Hispanic recipients increased 146.9% and 149.3%, respectively (Figure HR 54). When compared with adult heart transplant recipients in 2011, adult recipients in 2021 were older, more often male, and more often White, although there were more non-Whites than in 2011. The prevalence of recipients with Medicaid as the primary payer increased from 9.8% to 14.4% (Table HR 7). In general, adult recipients received a heart transplant for cardiomyopathy and were most likely to have blood type O or A. Fifty-nine percent of patients had calculated panel-reactive antibody < 20% in 2021; however, this value was missing for 28.2% of recipients, a marked increase from 3.3% missingness in panel-reactive antibody in 2011 (Table HR 8).

The number of recipients who received a transplant as status 1A increased from 2010 to 2017, whereas the number of status 2 recipients declined. In 2018, there was a decline in status 1A and 1B recipients, but an increase in status 2 recipients. The number of transplants under the new statuses is expectedly low in 2018; however, from 2019 through 2021, there was an increase in transplants among all statuses except 3, 4, and 5. In 2021, recipients were most often status 2 (50.2%) at the time of transplant, followed by status 4 (18.8%). In 2020, some centers elected to perform transplant in only the highest-urgency candidates due to the pandemic; however, heart transplants among status 1, 2, and 3 recipients declined nationwide and increased among the other statuses during 2020 compared with 2019 (Figure HR 56). Waiting times may be decreasing. Compared with 2011, more patients in 2021 underwent transplant within 90 days of listing (63.5%), and fewer waited 3 months to <2 years (Table HR 9). Trends in life support continue with an increasing prevalence of short-term devices. The number of patients with any life support increased, although the proportion declined from 81.9% in 2018 to 76.3% in 2021. In 2021, fewer patients had left ventricular assist devices before transplant (31.4%), while the prevalence of intra-aortic balloon use increased to 27.6% from 9.4% in 2018. ECMO prior to transplant also increased more than 3-fold (Table HR 6).

The use of induction therapy has varied over time. In 2013 through 2018, there was slightly more use of induction therapy, but this has declined again. In 2021, 49.0% of recipients received induction therapy (Figure HR 57). Triple immunosuppressive therapy (ie, tacrolimus, mycophenolate mofetil [MMF], and steroids) is the most common regimen at the time of transplant, and its use has increased from 73.3% to 83.9% from 2010 to 2021. The use of only tacrolimus and MMF also increased slightly to 8.0% in 2021 (Figure HR 58).

2.6 Outcomes

Six-month and 1-year mortality trends have fluctuated slightly since 2010 but remained constant in 2020. Six-month mortality peaked at 8.8% in 2014 and reached a nadir of 6.5% in 2018. One-year mortality was lowest at 7.9% in 2018 and peaked at 10.8% in 2014. In the transplant year 2020, 6-month mortality was 7.4%. One-year mortality followed a similar trend and in 2020 was 9.2%. Both 3-year and 5-year mortality have declined (Figure HR 59). Five-year survival is comparable between age groups. During the first year of transplant, candidates aged 65 years or older had the greatest decrease in survival, 11.8% (Figure HR 60). Hispanic recipients had an early decline in survival from 99.7% to 88.0% in the first year, while recipients categorized as other race and ethnicity tended to have a slight survival advantage throughout 5 years (Figure HR 61).

Survival varied by cause of heart failure. Recipients with valvular heart disease and other/unknown cause tended to have better survival throughout the first 4 years of transplant, whereas candidates with congenital heart disease had the lowest survival. Survival declined early among recipients with congenital heart disease to 88.7% at 3 months compared with >90% in other categories. This trend persisted, and at 5 years survival was 74.3% in recipients with congenital heart disease, the lowest of the diagnosis groups (Figure HR 62). Recipients with VADs had lower survival at 5 years than those without VADs (78.4% vs 82.3%, respectively), with curves separating at approximately 6 months (Figure HR 64). Recipients who received a heart transplant as status 2 in 2014-2016 (prior policy) had an early decrease in survival compared with statuses 1A and 1B; by 5 years, survival for status 2 recipients was 75.5% compared with 82.1% for status 1B and 79.9% for status 1A (Figure HR 65). Five-year survival did not vary by sex or place of residence (Figures HR 63 and 66).

The incidence of acute rejection at 1-year posttransplant has not changed appreciably over the past decade and occurred in 31.8% of 18- to 34-year old recipients who received a transplant in 2020 and in 18.6% of recipients aged 65 years or older (Figure HR 67). The cumulative incidence of posttransplant lymphoproliferative disorder at 5 years remains constant, 1.1%, occurring 3 times more frequently among recipients who are Epstein-Barr virus (EBV) seronegative (Figure HR 68).

3 PEDIATRIC HEART TRANSPLANT

3.1 Pediatric Waitlist Trends

In 2021, 703 new pediatric candidates were added to the heart transplant waiting list, and a total of 1,146 candidates aged 17 years or younger were awaiting heart transplant, which is a 39.8% increase from 2010 (Figures HR 69 and 70). The largest pediatric age groups on the waiting list in 2021 were 1-5 years (26.4%) and 12-17 years (28.4%), followed by younger than 1 year (21.3%) and 6-11 years (18.0%) (Figure HR 71). Just over half of pediatric heart transplant candidates were White (51.3%), 21.0% were Hispanic, 19.6% were Black, and 4.2% were Asian (Figure HR 72). Congenital defects continued to be the leading diagnosis among pediatric heart transplant candidates, at 57.3% in 2021, an increase of 23.7% since 2010 (Figure HR 73). Over the past decade, the proportion of candidates who were White has decreased from 58.5% in 2011 to 49.3% in 2021 (Table HR 10). For candidates waiting on December 31, 2021, congenital defect was the leading cause of heart disease, at 64.1%, compared with 46.3% in 2011 (Table HR 11). The proportion of candidates listed with a VAD increased from 3.8% in 2011 to 8.5% in 2021 (Table HR 11). Among the 661 candidates removed from the waiting list in 2021, 505 (76.4%) were removed due to undergoing transplant, 46 (7.0%) died, 40 (6.1%) were removed due to improved condition, and 33 (5.0%) were considered too sick to undergo transplant (Tables HR 13 and 14).

In 2021, 40.7% of pediatric heart transplant candidates on the waiting list had been waiting for fewer than 90 days (Figure HR 75). Almost half (48.2%) of these were status 1A candidates in 2021, followed by 18% status 1B and 11.0% status 2 (Figure HR 76). Just over 70% of pediatric candidates newly listed during 2016-2018 underwent transplant within 3 years, 10.1% died, 15.0% were removed from the list, and 4.6% were still waiting (Figure HR 77). After decreasing to its lowest rate in the past decade in 2020 (107.7 transplants per 100 patient-years), the pediatric heart transplant rate in 2021 increased to 113.0 transplants per 100 patient-years (Figure HR 78). Transplant rates in 2021 varied by age, with the highest rates for candidates aged 12-17 years (166.7 transplants per 100 patient-years), followed by younger than 1 year (161.8 transplants per 100 patient-years), 6-11 years (105.5 transplants per 100 patient-years), and 1-5 years (65.4 transplants per 100 patient-years) (Figure HR 79). Transplant rates in 2021 were similar among pediatric waitlist candidates by race (Figure HR 80). The pretransplant mortality decreased by 50.2%, from 21.9 deaths per 100 patient-years in 2010 to 10.9 deaths per 100 patient-years in 2021 (Figure HR 82). Pretransplant mortality rates in 2021 varied by age, with the highest rates in candidates younger than 1 year, at 29.8 deaths per 100 patient-years, followed by 8.7 for ages 1-5 years, 8.3 for 12-17 years, and 1.1 for 6-11 years (Figure HR 83). Looking at pretransplant mortality by race in 2021, rates were 12.4 deaths per 100 patient-years among Black candidates, 11.9 deaths per 100 patient-years among Hispanic candidates, 10.7 deaths per 100 patient-years among White candidates, and 5.2 deaths per 100 patient-years among Asian candidates (Figure HR 84). Pretransplant mortality in 2021 was highest for status 1A (30.1 deaths per 100 patient-years) candidates followed by status 1B (5.8 deaths per 100 patient-years) and status 2 (4.2 deaths per 100 patient-years) candidates among active statuses (Figure HR 86). Pretransplant mortality rates were similar for heart transplant candidates listed in metropolitan and non-metropolitan areas in 2021 (Figure HR 87).

3.2 Pediatric Trends in Heart Transplant

The number of pediatric heart transplants performed increased to 490 in 2021, a 36.1% increase from 2010 (Figure HR 88). There were 184 (37.6%) heart transplants performed in recipients aged 12-17 years, 111 (22.7%) in recipients younger than 1 year, 107 (21.8%) in recipients aged 1-5 years, and 88 (18.0%) in recipients aged 6-11 years (Figure HR 89). Over the past few years, the proportion of transplant recipients aged 12-17 years has increased (30.5% in 2016 compared with 37.6% in 2021) (Table HR 16). Sex, as well as race and ethnicity, of pediatric heart transplant recipients has remained stable (Table HR 16). Just over half of pediatric heart transplant recipients in 2021 had congenital defect as their primary cause of disease (Table HR 17). The proportion who underwent transplant at status 1A declined from 89.3% in 2011 to 81.8% in 2021, while the proportion at status 1B increased from 6.9% to 16.7% and the proportion at status 2 declined from 3.7% to 1.4%. The proportion of heart transplant recipients with a VAD at transplant increased by 89.9%, from 18.9% in 2011 to 35.9% in 2021 (Table HR 17). The proportion of ABO-incompatible transplants has increased from 3.7% in 2011 to 8.6% in 2021 (Table HR 18).

Over the past decade, induction therapy use has increased, to 84.9% of pediatric heart transplant recipients in 2021 (Figure HR 94). The initial immunosuppression regimens used most commonly in 2021 were tacrolimus, MMF, and steroids in 48.8% of pediatric heart transplant recipients (Figure HR 95). There has been a steady increase in the use of a tacrolimus and MMF regimen, to almost 40% in 2021 (Figure HR 95).

3.3 Pediatric Posttransplant Survival and Morbidity

Among pediatric heart transplant recipients in 2020, the rate of acute rejection in the first year was 23.0% in recipients aged 1-5 years, 19.9% in those aged 12-17 years, 16.1% in those younger than 1 year, and 13.0% in those aged 6-11 years (Figure HR 96).

Recipient death occurred in 4.7% of patients at 6-months posttransplant and in 6.9% at 1-year posttransplant among pediatric heart transplants performed in 2020, in 13.1% at 3 years for transplants performed in 2018, in 13.7% at 5 years for transplants performed in 2016, and in 31.5% at 10 years for transplants performed in 2011 (Figure HR 98). Overall, 1- and 5-year patient survival rates were 92.7% and 84.3%, respectively, among recipients who underwent transplant in 2014-2016 (Figure HR 99). By age, 5-year patient survival was 82.2% for recipients younger than 1 year, 83.4% for those aged 1-5 years, 88.0% for those aged 6-11 years, and 84.9% for those aged 12-17 years (Figure HR 100).

Among pediatric heart transplant recipients in 2010-2016, the overall incidence of posttransplant lymphoproliferative disorder was 4.7% at 5 years; incidence was 6.1% among EBV-negative recipients and 3.3% among EBV-positive recipients (Figure HR 97).

This publication was produced for the U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA), by Hennepin Healthcare Research Institute (HHRI) and the United Network for Organ Sharing (UNOS) under contracts HHSH75R60220C00011 and HHSH250201900001C, respectively.

This publication lists nonfederal resources in order to provide additional information to consumers. The views and content in these resources have not been formally approved by HHS or HRSA. Neither HHS nor HRSA endorses the products or services of the listed resources.

The OPTN/SRTR 2021 Annual Data Report is not copyrighted. Readers are free to duplicate and use all or part of the information contained in this publication. Data are not copyrighted and may be used without permission if appropriate citation information is provided.

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Suggested Citations:
Full citation: Organ Procurement and Transplantation Network (OPTN) and Scientific Registry of Transplant Recipients (SRTR). OPTN/SRTR 2021 Annual Data Report. U.S. Department of Health and Human Services, Health Resources and Services Administration; 2023. Accessed [insert date]. http://srtr.transplant.hrsa.gov/annual_reports/Default.aspx
Abbreviated citation: OPTN/SRTR 2021 Annual Data Report. HHS/HRSA; 2023. Accessed [insert date]. http://srtr.transplant.hrsa.gov/annual_reports/Default.aspx

Publications based on data in this report or supplied on request must include a citation and the following statement: The data and analyses reported in the OPTN/SRTR 2021 Annual Data Report have been supplied by the United Network for Organ Sharing and Hennepin Healthcare Research Institute under contract with HHS/HRSA. The authors alone are responsible for reporting and interpreting these data; the views expressed herein are those of the authors and not necessarily those of the U.S. government.

This report is available at https://srtr.transplant.hrsa.gov. Individual chapters may be downloaded.

List of Figures

Figure HR 1: New adult candidates added to the heart transplant waiting list
Figure HR 2: All adult candidates on the heart transplant waiting list
Figure HR 3: Distribution of adults waiting for heart transplant by age
Figure HR 4: Distribution of adults waiting for heart transplant by sex
Figure HR 5: Distribution of adults waiting for heart transplant by race
Figure HR 6: Distribution of adults waiting for heart transplant by diagnosis
Figure HR 7: Distribution of adults waiting for heart transplant by waiting time
Figure HR 8: Distribution of adults waiting for heart transplant by former medical urgency groups through October 17, 2018
Figure HR 9: Distribution of adults waiting for heart transplant by new medical urgency groups, October 18, 2018, through 2021
Figure HR 10: Distribution of adults waiting for heart transplant by BMI
Figure HR 11: Distribution of adults waiting for heart transplant by blood type
Figure HR 12: Distribution of adults waiting for heart transplant by prior transplant status
Figure HR 13: Overall deceased donor heart transplant rates among adult waitlist candidates
Figure HR 14: Deceased donor heart transplant rates among adult waitlist candidates by age
Figure HR 15: Deceased donor heart transplant rates among adult waitlist candidates by race
Figure HR 16: Deceased donor heart transplant rates among adult waitlist candidates by diagnosis
Figure HR 17: Deceased donor heart transplant rates among adult waitlist candidates by blood type
Figure HR 18: Deceased donor heart transplant rates among adult waitlist candidates by sex
Figure HR 19: Deceased donor heart transplant rates among adult waitlist candidates by former medical urgency groups through October 17, 2018
Figure HR 20: Deceased donor heart transplant rates among adult waitlist candidates by new medical urgency groups, October 18, 2018, through 2021
Figure HR 21: Deceased donor heart transplant rates among adult waitlist candidates by height
Figure HR 22: Deceased donor heart transplant rates among adult waitlist candidates by metropolitan vs. non-metropolitan residence
Figure HR 23: Three-year outcomes for adults waiting for heart transplant, new listings in 2016-2018
Figure HR 24: Percentage of adults who underwent deceased donor heart transplant within a given period of listing
Figure HR 25: Overall pretransplant mortality rates among adults waitlisted for heart transplant
Figure HR 26: Pretransplant mortality rates among adults waitlisted for heart transplant by age
Figure HR 27: Pretransplant mortality rates among adults waitlisted for heart transplant by race
Figure HR 28: Pretransplant mortality rates among adults waitlisted for heart transplant by sex
Figure HR 29: Pretransplant mortality rates among adults waitlisted for heart transplant by diagnosis
Figure HR 30: Pretransplant mortality rates among adults waitlisted for heart transplant by metropolitan vs. non-metropolitan residence
Figure HR 31: Pretransplant mortality rates among adults waitlisted for heart transplant by former medical urgency groups through October 17, 2018
Figure HR 32: Pretransplant mortality rates among adults waitlisted for heart transplant by new medical urgency groups, October 18, 2018, through 2021
Figure HR 33: Pretransplant mortality rates among adults waitlisted for heart transplant in 2021 by DSA
Figure HR 34: Deaths within six months after removal among adult heart waitlist candidates, overall
Figure HR 35: Deaths within six months after removal among adult heart waitlist candidates, by age
Figure HR 36: Deaths within six months after removal among adult heart waitlist candidates, by status at removal
Figure HR 37: Overall deceased heart donor count
Figure HR 38: Deceased heart donor count by age
Figure HR 39: Distribution of deceased heart donors by age
Figure HR 40: Distribution of deceased heart donors by sex
Figure HR 41: Distribution of deceased heart donors by race
Figure HR 42: Cause of death among deceased heart donors
Figure HR 43: Overall percent of hearts recovered for transplant and not transplanted
Figure HR 44: Percent of hearts recovered for transplant and not transplanted by donor age
Figure HR 45: Percent of hearts recovered for transplant and not transplanted by donor sex
Figure HR 46: Percent of hearts recovered for transplant and not transplanted by donor race
Figure HR 47: Percent of hearts recovered for transplant and not transplanted by donor hypertension status
Figure HR 48: Percent of hearts recovered for transplant and not transplanted by donor BMI
Figure HR 49: Percent of hearts recovered for transplant and not transplanted by donor cause of death
Figure HR 50: Percent of hearts recovered for transplant and not transplanted, by donor risk of disease transmission
Figure HR 51: Overall adult heart transplants
Figure HR 52: Adult heart transplants by age
Figure HR 53: Adult heart transplants by sex
Figure HR 54: Adult heart transplants by race
Figure HR 55: Adult heart transplants by diagnosis
Figure HR 56: Adult heart transplants by medical urgency
Figure HR 57: Induction agent use in adult heart transplant recipients
Figure HR 58: Immunosuppression regimen use in adult heart transplant recipients
Figure HR 59: Patient death among adult heart transplant recipients
Figure HR 60: Patient survival among adult heart transplant recipients, 2014-2016, by age
Figure HR 61: Patient survival among adult heart transplant recipients, 2014-2016, by race
Figure HR 62: Patient survival among adult heart transplant recipients, 2014-2016, by diagnosis group
Figure HR 63: Patient survival among adult heart transplant recipients, 2014-2016, by sex
Figure HR 64: Patient survival among adult heart transplant recipients, 2014-2016, by VAD status
Figure HR 65: Patient survival among adult heart transplant recipients, 2014-2016, by medical urgency
Figure HR 66: Patient survival among adult heart transplant recipients, 2014-2016, by metropolitan vs. non-metropolitan recipient residence
Figure HR 67: Incidence of acute rejection by 1 year posttransplant among adult heart transplant recipients by age
Figure HR 68: Incidence of PTLD among adult heart transplant recipients by recipient EBV status at transplant, 2010-2016
Figure HR 69: New pediatric candidates added to the heart transplant waiting list
Figure HR 70: All pediatric candidates on the heart transplant waiting list
Figure HR 71: Distribution of pediatric candidates waiting for heart transplant by age
Figure HR 72: Distribution of pediatric candidates waiting for heart transplant by race
Figure HR 73: Distribution of pediatric candidates waiting for heart transplant by diagnosis
Figure HR 74: Distribution of pediatric candidates waiting for heart transplant by sex
Figure HR 75: Distribution of pediatric candidates waiting for heart transplant by waiting time
Figure HR 76: Distribution of pediatric candidates waiting for heart transplant by medical urgency
Figure HR 77: Three-year outcomes for newly listed pediatric candidates waiting for heart transplant, 2016-2018
Figure HR 78: Overall deceased donor heart transplant rates among pediatric waitlist candidates
Figure HR 79: Deceased donor heart transplant rates among pediatric waitlist candidates by age
Figure HR 80: Deceased donor heart transplant rates among pediatric waitlist candidates by race
Figure HR 81: Deceased donor heart transplant rates among pediatric waitlist candidates by metropolitan vs. non-metropolitan residence
Figure HR 82: Overall pretransplant mortality rates among pediatric candidates waitlisted for heart
Figure HR 83: Pretransplant mortality rates among pediatric candidates waitlisted for heart transplant by age
Figure HR 84: Pretransplant mortality rates among pediatric candidates waitlisted for heart transplant by race
Figure HR 85: Pretransplant mortality rates among pediatrics waitlisted for heart transplant by diagnosis
Figure HR 86: Pretransplant mortality rates among pediatrics waitlisted for heart transplant by medical urgency
Figure HR 87: Pretransplant mortality rates among pediatric candidates waitlisted for heart transplant by metropolitan vs. non-metropolitan residence
Figure HR 88: Overall pediatric heart transplants
Figure HR 89: Pediatric heart transplants by recipient age
Figure HR 90: Pediatric heart transplants by sex
Figure HR 91: Pediatric heart transplants by race
Figure HR 92: Pediatric heart transplants by diagnosis
Figure HR 93: Pediatric heart transplants by medical urgency
Figure HR 94: Induction agent use in pediatric heart transplant recipients
Figure HR 95: Immunosuppression regimen use in pediatric heart transplant recipients
Figure HR 96: Incidence of acute rejection by 1 year posttransplant among pediatric heart transplant recipients by age
Figure HR 97: Incidence of PTLD among pediatric heart transplant recipients by recipient EBV status at transplant, 2010-2016
Figure HR 98: Patient death among pediatric heart transplant recipients
Figure HR 99: Overall patient survival among pediatric deceased donor heart transplant recipients, 2014-2016
Figure HR 100: Patient survival among pediatric deceased donor heart transplant recipients, 2014-2016, by recipient age

List of Tables

Table HR 1: Demographic characteristics of adults on the heart transplant waiting list on December 31, 2011, and December 31, 2021
Table HR 2: Clinical characteristics of adults on the heart transplant waiting list on December 31, 2011, and December 31, 2021
Table HR 3: Listing characteristics of adults on the heart transplant waiting list on December 31, 2011, and December 31, 2021
Table HR 4: Heart transplant waitlist activity among adults
Table HR 5: Removal reason among adult heart transplant candidates
Table HR 6: Adult heart recipients on life support before transplant
Table HR 7: Demographic characteristics of adult heart transplant recipients, 2011 and 2021
Table HR 8: Clinical characteristics of adult heart transplant recipients, 2011 and 2021
Table HR 9: Transplant characteristics of adult heart transplant recipients, 2011 and 2021
Table HR 10: Demographic characteristics of pediatric candidates on the heart transplant waiting list on December 31, 2011 and December 31, 2021
Table HR 11: Clinical characteristics of pediatric candidates on the heart transplant waiting list on December 31, 2011, and December 31, 2021
Table HR 12: Listing characteristics of pediatric candidates on the heart transplant waiting list on December 31, 2011, and December 31, 2021
Table HR 13: Heart transplant waitlist activity among pediatric candidates
Table HR 14: Removal reason among pediatric heart transplant candidates
Table HR 15: Pediatric heart recipients on life support before transplant
Table HR 16: Demographic characteristics of pediatric heart transplant recipients, 2011 and 2021
Table HR 17: Clinical characteristics of pediatric heart transplant recipients, 2011 and 2021
Table HR 18: Transplant characteristics of pediatric heart transplant recipients, 2011 and 2021

**New adult candidates added to the heart transplant waiting list.** A new adult candidate is one who first joined the list during the given year, without having been listed in a previous year. Previously listed candidates who underwent transplant and subsequently relisted are considered new. Active and inactive patients are included.

Figure HR 1: New adult candidates added to the heart transplant waiting list. A new adult candidate is one who first joined the list during the given year, without having been listed in a previous year. Previously listed candidates who underwent transplant and subsequently relisted are considered new. Active and inactive patients are included.

**All adult candidates on the heart transplant waiting list.** Adult candidates on the list at any time during the year. Candidates listed at more than one center are counted once per listing.

Figure HR 2: All adult candidates on the heart transplant waiting list. Adult candidates on the list at any time during the year. Candidates listed at more than one center are counted once per listing.

**Distribution of adults waiting for heart transplant by age.** Candidates waiting for transplant at any time in the given year. Candidates listed at more than one center are counted once per listing. Active and inactive candidates are included. Age is determined at the earliest of transplant, death, removal, or December 31 of the year.

Figure HR 3: Distribution of adults waiting for heart transplant by age. Candidates waiting for transplant at any time in the given year. Candidates listed at more than one center are counted once per listing. Active and inactive candidates are included. Age is determined at the earliest of transplant, death, removal, or December 31 of the year.

**Distribution of adults waiting for heart transplant by sex.** Candidates waiting for transplant at any time in the given year. Candidates listed at more than one center are counted once per listing. Active and inactive patients are included.

Figure HR 4: Distribution of adults waiting for heart transplant by sex. Candidates waiting for transplant at any time in the given year. Candidates listed at more than one center are counted once per listing. Active and inactive patients are included.

**Distribution of adults waiting for heart transplant by race.** Candidates waiting for transplant at any time in the given year. Candidates listed at more than one center are counted once per listing. Active and inactive patients are included.

Figure HR 5: Distribution of adults waiting for heart transplant by race. Candidates waiting for transplant at any time in the given year. Candidates listed at more than one center are counted once per listing. Active and inactive patients are included.

**Distribution of adults waiting for heart transplant by diagnosis.** Candidates waiting for transplant at any time in the given year. Active and inactive patients are included. Candidates listed at more than one center are counted once per listing.

Figure HR 6: Distribution of adults waiting for heart transplant by diagnosis. Candidates waiting for transplant at any time in the given year. Active and inactive patients are included. Candidates listed at more than one center are counted once per listing.

**Distribution of adults waiting for heart transplant by waiting time.** Candidates waiting for transplant at any time in the given year. Candidates listed at more than one center are counted once per listing. Time on the waiting list is determined at the earliest of transplant, death, removal, or December 31 of the year. Active and inactive candidates are included.

Figure HR 7: Distribution of adults waiting for heart transplant by waiting time. Candidates waiting for transplant at any time in the given year. Candidates listed at more than one center are counted once per listing. Time on the waiting list is determined at the earliest of transplant, death, removal, or December 31 of the year. Active and inactive candidates are included.

**Distribution of adults waiting for heart transplant by former medical urgency groups through October 17, 2018.** Candidates waiting for transplant at any time in the given year. Candidates listed at more than one center are counted once per listing. Active and inactive candidates are included. The October 2018 OPTN heart allocation policy update changed the status groups. Medical urgency for 2017 and earlier is determined at the earliest of transplant, death, removal, or December 31 of the year. For 2018 medical urgency statuses, statuses 1A, 1B, and 2 were determined at the earliest of transplant, death, or removal. For candidates who stayed active on the waiting list on or after October 18, 2018, and for candidates who were newly waitlisted on or after that date through 2021, their statuses are shown in Figure HR 9. Inactive statuses with new listings on or after October 18, 2018, are excluded here in Figure HR 8.

Figure HR 8: Distribution of adults waiting for heart transplant by former medical urgency groups through October 17, 2018. Candidates waiting for transplant at any time in the given year. Candidates listed at more than one center are counted once per listing. Active and inactive candidates are included. The October 2018 OPTN heart allocation policy update changed the status groups. Medical urgency for 2017 and earlier is determined at the earliest of transplant, death, removal, or December 31 of the year. For 2018 medical urgency statuses, statuses 1A, 1B, and 2 were determined at the earliest of transplant, death, or removal. For candidates who stayed active on the waiting list on or after October 18, 2018, and for candidates who were newly waitlisted on or after that date through 2021, their statuses are shown in Figure HR 9. Inactive statuses with new listings on or after October 18, 2018, are excluded here in Figure HR 8.

**Distribution of adults waiting for heart transplant by new medical urgency groups, October 18, 2018, through 2021.** Candidates waiting for transplant at any time in the given year. Candidates listed at more than one center are counted once per listing. Active and inactive candidates are included. The October 2018 OPTN heart allocation policy update changed the status groups. Medical urgency is determined at the earliest of transplant, death, removal, or December 31 of the year. For 2018 medical urgency statuses, statuses 1-6 and inactive status contain new listings on or after October 18, 2018, or existing listings from before the policy change.

Figure HR 9: Distribution of adults waiting for heart transplant by new medical urgency groups, October 18, 2018, through 2021. Candidates waiting for transplant at any time in the given year. Candidates listed at more than one center are counted once per listing. Active and inactive candidates are included. The October 2018 OPTN heart allocation policy update changed the status groups. Medical urgency is determined at the earliest of transplant, death, removal, or December 31 of the year. For 2018 medical urgency statuses, statuses 1-6 and inactive status contain new listings on or after October 18, 2018, or existing listings from before the policy change.

**Distribution of adults waiting for heart transplant by BMI.** Candidates waiting for transplant at any time in the given year. Candidates listed at more than one center are counted once per listing. Active and inactive patients are included.

Figure HR 10: Distribution of adults waiting for heart transplant by BMI. Candidates waiting for transplant at any time in the given year. Candidates listed at more than one center are counted once per listing. Active and inactive patients are included.

**Distribution of adults waiting for heart transplant by blood type.** Candidates waiting for transplant at any time in the given year. Candidates listed at more than one center are counted once per listing. Active and inactive patients are included.

Figure HR 11: Distribution of adults waiting for heart transplant by blood type. Candidates waiting for transplant at any time in the given year. Candidates listed at more than one center are counted once per listing. Active and inactive patients are included.

**Distribution of adults waiting for heart transplant by prior transplant status.** Candidates waiting for transplant at any time in the given year. Candidates listed at more than one center are counted once per listing. Active and inactive patients are included.

Figure HR 12: Distribution of adults waiting for heart transplant by prior transplant status. Candidates waiting for transplant at any time in the given year. Candidates listed at more than one center are counted once per listing. Active and inactive patients are included.

**Overall deceased donor heart transplant rates among adult waitlist candidates.** Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of wait time in a given year. Individual listings are counted separately.

Figure HR 13: Overall deceased donor heart transplant rates among adult waitlist candidates. Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of wait time in a given year. Individual listings are counted separately.

**Deceased donor heart transplant rates among adult waitlist candidates by age.** Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of wait time in a given year. Individual listings are counted separately. Age is determined at the later of listing date or January 1 of the given year.

Figure HR 14: Deceased donor heart transplant rates among adult waitlist candidates by age. Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of wait time in a given year. Individual listings are counted separately. Age is determined at the later of listing date or January 1 of the given year.

**Deceased donor heart transplant rates among adult waitlist candidates by race.** Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of wait time in a given year. Individual listings are counted separately.

Figure HR 15: Deceased donor heart transplant rates among adult waitlist candidates by race. Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of wait time in a given year. Individual listings are counted separately.

**Deceased donor heart transplant rates among adult waitlist candidates by diagnosis.** Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of wait time in a given year. Individual listings are counted separately.

Figure HR 16: Deceased donor heart transplant rates among adult waitlist candidates by diagnosis. Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of wait time in a given year. Individual listings are counted separately.

**Deceased donor heart transplant rates among adult waitlist candidates by blood type.** Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of wait time in a given year. Individual listings are counted separately.

Figure HR 17: Deceased donor heart transplant rates among adult waitlist candidates by blood type. Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of wait time in a given year. Individual listings are counted separately.

**Deceased donor heart transplant rates among adult waitlist candidates by sex.** Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of wait time in a given year. Individual listings are counted separately.

Figure HR 18: Deceased donor heart transplant rates among adult waitlist candidates by sex. Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of wait time in a given year. Individual listings are counted separately.

**Deceased donor heart transplant rates among adult waitlist candidates by former medical urgency groups through October 17, 2018.** Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of wait time in a given year. Individual listings are counted separately. The October 2018 OPTN heart allocation policy update changed the status groups. Medical urgency is determined at the later of listing date or January 1 of the given year. For new listings on or after October 18, 2018, and for candidates who were newly waitlisted on or after that date through 2021, their medical urgency statuses are shown in Figure HR 20. Inactive statuses with new listings on or after October 18, 2018, are excluded here in Figure HR 19.

Figure HR 19: Deceased donor heart transplant rates among adult waitlist candidates by former medical urgency groups through October 17, 2018. Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of wait time in a given year. Individual listings are counted separately. The October 2018 OPTN heart allocation policy update changed the status groups. Medical urgency is determined at the later of listing date or January 1 of the given year. For new listings on or after October 18, 2018, and for candidates who were newly waitlisted on or after that date through 2021, their medical urgency statuses are shown in Figure HR 20. Inactive statuses with new listings on or after October 18, 2018, are excluded here in Figure HR 19.

**Deceased donor heart transplant rates among adult waitlist candidates by new medical urgency groups, October 18, 2018, through 2021.** Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of wait time in a given year. Individual listings are counted separately. The October 2018 OPTN heart allocation policy update changed the status groups. Medical urgency is determined at the later of listing date or January 1 of the given year. For 2018 medical urgency statuses, statuses 1-6 and inactive status contain new listings on or after October 18, 2018.

Figure HR 20: Deceased donor heart transplant rates among adult waitlist candidates by new medical urgency groups, October 18, 2018, through 2021. Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of wait time in a given year. Individual listings are counted separately. The October 2018 OPTN heart allocation policy update changed the status groups. Medical urgency is determined at the later of listing date or January 1 of the given year. For 2018 medical urgency statuses, statuses 1-6 and inactive status contain new listings on or after October 18, 2018.

**Deceased donor heart transplant rates among adult waitlist candidates by height.** Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of wait time in a given year. Individual listings are counted separately.

Figure HR 21: Deceased donor heart transplant rates among adult waitlist candidates by height. Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of wait time in a given year. Individual listings are counted separately.

**Deceased donor heart transplant rates among adult waitlist candidates by metropolitan vs. non-metropolitan residence.** Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of wait time in a given year. Individual listings are counted separately. Urban/rural determination is made using the RUCA (rural-urban commuting area) designation of the candidate's permanent zip code.

Figure HR 22: Deceased donor heart transplant rates among adult waitlist candidates by metropolitan vs. non-metropolitan residence. Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of wait time in a given year. Individual listings are counted separately. Urban/rural determination is made using the RUCA (rural-urban commuting area) designation of the candidate’s permanent zip code.

**Three-year outcomes for adults waiting for heart transplant, new listings in 2016-2018.** Candidates listed at more than one center are counted once per listing. Removed from list includes all reasons except transplant and death. DD, deceased donor.

Figure HR 23: Three-year outcomes for adults waiting for heart transplant, new listings in 2016-2018. Candidates listed at more than one center are counted once per listing. Removed from list includes all reasons except transplant and death. DD, deceased donor.

**Percentage of adults who underwent deceased donor heart transplant within a given period of listing.** Candidates listed at more than one center are counted once per listing.

Figure HR 24: Percentage of adults who underwent deceased donor heart transplant within a given period of listing. Candidates listed at more than one center are counted once per listing.

**Overall pretransplant mortality rates among adults waitlisted for heart transplant.** Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Individual listings are counted separately.

Figure HR 25: Overall pretransplant mortality rates among adults waitlisted for heart transplant. Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Individual listings are counted separately.

**Pretransplant mortality rates among adults waitlisted for heart transplant by age.** Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Individual listings are counted separately. Age is determined at the later of listing date or January 1 of the given year.

Figure HR 26: Pretransplant mortality rates among adults waitlisted for heart transplant by age. Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Individual listings are counted separately. Age is determined at the later of listing date or January 1 of the given year.

**Pretransplant mortality rates among adults waitlisted for heart transplant by race.** Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Individual listings are counted separately.

Figure HR 27: Pretransplant mortality rates among adults waitlisted for heart transplant by race. Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Individual listings are counted separately.

**Pretransplant mortality rates among adults waitlisted for heart transplant by sex.** Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Individual listings are counted separately.

Figure HR 28: Pretransplant mortality rates among adults waitlisted for heart transplant by sex. Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Individual listings are counted separately.

**Pretransplant mortality rates among adults waitlisted for heart transplant by diagnosis.** Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Individual listings are counted separately.

Figure HR 29: Pretransplant mortality rates among adults waitlisted for heart transplant by diagnosis. Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Individual listings are counted separately.

**Pretransplant mortality rates among adults waitlisted for heart transplant by metropolitan vs. non-metropolitan residence.** Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Individual listings are counted separately. Urban/rural determination is made using the RUCA (rural-urban commuting area) designation of the candidate's permanent zip code.

Figure HR 30: Pretransplant mortality rates among adults waitlisted for heart transplant by metropolitan vs. non-metropolitan residence. Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Individual listings are counted separately. Urban/rural determination is made using the RUCA (rural-urban commuting area) designation of the candidate’s permanent zip code.

**Pretransplant mortality rates among adults waitlisted for heart transplant by former medical urgency groups through October 17, 2018.** Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Individual listings are counted separately. Medical urgency is determined at the later of listing date or January 1 of the given year. The October 2018 OPTN heart allocation policy update changed the status groups. For 2018 medical urgency statuses, new listings on or after October 18, 2018, are not shown in this figure.

Figure HR 31: Pretransplant mortality rates among adults waitlisted for heart transplant by former medical urgency groups through October 17, 2018. Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Individual listings are counted separately. Medical urgency is determined at the later of listing date or January 1 of the given year. The October 2018 OPTN heart allocation policy update changed the status groups. For 2018 medical urgency statuses, new listings on or after October 18, 2018, are not shown in this figure.

**Pretransplant mortality rates among adults waitlisted for heart transplant by new medical urgency groups, October 18, 2018, through 2021.** Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Individual listings are counted separately. Medical urgency is determined at the later of listing date or January 1 of the given year. The October 2018 OPTN heart allocation policy update changed the status groups. For 2018 medical urgency statuses, statuses 1-6 and inactive status contain new listings on or after October 18, 2018.

Figure HR 32: Pretransplant mortality rates among adults waitlisted for heart transplant by new medical urgency groups, October 18, 2018, through 2021. Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Individual listings are counted separately. Medical urgency is determined at the later of listing date or January 1 of the given year. The October 2018 OPTN heart allocation policy update changed the status groups. For 2018 medical urgency statuses, statuses 1-6 and inactive status contain new listings on or after October 18, 2018.

**Pretransplant mortality rates among adults waitlisted for heart transplant in 2021 by DSA.** Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Individual listings are counted separately.

Figure HR 33: Pretransplant mortality rates among adults waitlisted for heart transplant in 2021 by DSA. Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Individual listings are counted separately.

**Deaths within six months after removal among adult heart waitlist candidates, overall.** Denominator includes only candidates removed from the waiting list for reasons other than transplant or death while on the list.

Figure HR 34: Deaths within six months after removal among adult heart waitlist candidates, overall. Denominator includes only candidates removed from the waiting list for reasons other than transplant or death while on the list.

**Deaths within six months after removal among adult heart waitlist candidates, by age.** Denominator includes only candidates removed from the waiting list for reasons other than transplant or death while on the list. Age is determined at removal.

Figure HR 35: Deaths within six months after removal among adult heart waitlist candidates, by age. Denominator includes only candidates removed from the waiting list for reasons other than transplant or death while on the list. Age is determined at removal.

**Deaths within six months after removal among adult heart waitlist candidates, by status at removal.** Denominator includes only candidates removed from the waiting list for reasons other than transplant or death while on the list. The October 2018 OPTN heart allocation policy update changed the status groups. The statuses 1A, 1B, and 2 listed first are through October 17, 2018, the last day before the policy update; the adult statuses listed are for October 18, 2018, and onward. Medical urgency is determined at the earliest of transplant, death, removal, or December 31 of the year.

Figure HR 36: Deaths within six months after removal among adult heart waitlist candidates, by status at removal. Denominator includes only candidates removed from the waiting list for reasons other than transplant or death while on the list. The October 2018 OPTN heart allocation policy update changed the status groups. The statuses 1A, 1B, and 2 listed first are through October 17, 2018, the last day before the policy update; the adult statuses listed are for October 18, 2018, and onward. Medical urgency is determined at the earliest of transplant, death, removal, or December 31 of the year.

Figure HR 37: Overall deceased heart donor count. Count of deceased donors whose hearts were recovered for transplant.

Figure HR 38: Deceased heart donor count by age. Count of deceased donors whose hearts were recovered for transplant.

Figure HR 39: Distribution of deceased heart donors by age. Deceased donors whose hearts were recovered for transplant.

Figure HR 40: Distribution of deceased heart donors by sex. Deceased donors whose hearts were recovered for transplant.

Figure HR 41: Distribution of deceased heart donors by race. Deceased donors whose hearts were recovered for transplant.

**Cause of death among deceased heart donors.** Deceased donors with a heart recovered for the purposes of transplant. CVA, cerebrovascular accident.

Figure HR 42: Cause of death among deceased heart donors. Deceased donors with a heart recovered for the purposes of transplant. CVA, cerebrovascular accident.

**Overall percent of hearts recovered for transplant and not transplanted.** Percentages of hearts not transplanted out of all hearts recovered for transplant.

Figure HR 43: Overall percent of hearts recovered for transplant and not transplanted. Percentages of hearts not transplanted out of all hearts recovered for transplant.

**Percent of hearts recovered for transplant and not transplanted by donor age.** Percentages of hearts not transplanted out of all hearts recovered for transplant.

Figure HR 44: Percent of hearts recovered for transplant and not transplanted by donor age. Percentages of hearts not transplanted out of all hearts recovered for transplant.

**Percent of hearts recovered for transplant and not transplanted by donor sex.** Percentages of hearts not transplanted out of all hearts recovered for transplant.

Figure HR 45: Percent of hearts recovered for transplant and not transplanted by donor sex. Percentages of hearts not transplanted out of all hearts recovered for transplant.

**Percent of hearts recovered for transplant and not transplanted by donor race.** Percentages of hearts not transplanted out of all hearts recovered for transplant.

Figure HR 46: Percent of hearts recovered for transplant and not transplanted by donor race. Percentages of hearts not transplanted out of all hearts recovered for transplant.

**Percent of hearts recovered for transplant and not transplanted by donor hypertension status.** Percentages of hearts not transplanted out of all hearts recovered for transplant.

Figure HR 47: Percent of hearts recovered for transplant and not transplanted by donor hypertension status. Percentages of hearts not transplanted out of all hearts recovered for transplant.

**Percent of hearts recovered for transplant and not transplanted by donor BMI.** Percentages of hearts not transplanted out of all hearts recovered for transplant.

Figure HR 48: Percent of hearts recovered for transplant and not transplanted by donor BMI. Percentages of hearts not transplanted out of all hearts recovered for transplant.

**Percent of hearts recovered for transplant and not transplanted by donor cause of death.** Percentages of hearts not transplanted out of all hearts recovered for transplant. CVA, cerebrovascular accident.

Figure HR 49: Percent of hearts recovered for transplant and not transplanted by donor cause of death. Percentages of hearts not transplanted out of all hearts recovered for transplant. CVA, cerebrovascular accident.

**Percent of hearts recovered for transplant and not transplanted, by donor risk of disease transmission.** Percentages of hearts not transplanted out of all hearts recovered for transplant. "Increased risk" is defined by criteria from the US Public Health Service Guidelines for increased risk for HIV, hepatitis B, and hepatitis C transmission.

Figure HR 50: Percent of hearts recovered for transplant and not transplanted, by donor risk of disease transmission. Percentages of hearts not transplanted out of all hearts recovered for transplant. “Increased risk” is defined by criteria from the US Public Health Service Guidelines for increased risk for HIV, hepatitis B, and hepatitis C transmission.

Figure HR 51: Overall adult heart transplants. All adult heart transplant recipients, including retransplant, and multiorgan recipients.

Figure HR 52: Adult heart transplants by age. All adult heart transplant recipients, including retransplant, and multiorgan recipients.

Figure HR 53: Adult heart transplants by sex. All adult heart transplant recipients, including retransplant, and multiorgan recipients.

Figure HR 54: Adult heart transplants by race. All adult heart transplant recipients, including retransplant, and multiorgan recipients.

Figure HR 55: Adult heart transplants by diagnosis. All adult heart transplant recipients, including retransplant, and multiorgan recipients.

**Adult heart transplants by medical urgency.** All adult heart transplant recipients, including retransplant, and multiorgan recipients. The October 2018 OPTN heart allocation policy update changed the status groups. The statuses 1A, 1B, and 2 listed first are through October 17, 2018, the last day before the policy update; the adult statuses listed are for October 18, 2018, and onward.

Figure HR 56: Adult heart transplants by medical urgency. All adult heart transplant recipients, including retransplant, and multiorgan recipients. The October 2018 OPTN heart allocation policy update changed the status groups. The statuses 1A, 1B, and 2 listed first are through October 17, 2018, the last day before the policy update; the adult statuses listed are for October 18, 2018, and onward.

Figure HR 57: Induction agent use in adult heart transplant recipients. Immunosuppression at transplant reported to the OPTN.

**Immunosuppression regimen use in adult heart transplant recipients.** Immunosuppression regimen at transplant reported to the OPTN. Tac, tacrolimus. MMF, all mycophenolate agents.

Figure HR 58: Immunosuppression regimen use in adult heart transplant recipients. Immunosuppression regimen at transplant reported to the OPTN. Tac, tacrolimus. MMF, all mycophenolate agents.

**Patient death among adult heart transplant recipients.** All adult recipients of deceased donor hearts, including multiorgan transplants.

Figure HR 59: Patient death among adult heart transplant recipients. All adult recipients of deceased donor hearts, including multiorgan transplants.

**Patient survival among adult heart transplant recipients, 2014-2016, by age.** Patient survival estimated using unadjusted Kaplan-Meier methods.

Figure HR 60: Patient survival among adult heart transplant recipients, 2014-2016, by age. Patient survival estimated using unadjusted Kaplan-Meier methods.

**Patient survival among adult heart transplant recipients, 2014-2016, by race.** Patient survival estimated using unadjusted Kaplan-Meier methods.

Figure HR 61: Patient survival among adult heart transplant recipients, 2014-2016, by race. Patient survival estimated using unadjusted Kaplan-Meier methods.

**Patient survival among adult heart transplant recipients, 2014-2016, by diagnosis group.** Patient survival estimated using unadjusted Kaplan-Meier methods.

Figure HR 62: Patient survival among adult heart transplant recipients, 2014-2016, by diagnosis group. Patient survival estimated using unadjusted Kaplan-Meier methods.

**Patient survival among adult heart transplant recipients, 2014-2016, by sex.** Patient survival estimated using unadjusted Kaplan-Meier methods.

Figure HR 63: Patient survival among adult heart transplant recipients, 2014-2016, by sex. Patient survival estimated using unadjusted Kaplan-Meier methods.

**Patient survival among adult heart transplant recipients, 2014-2016, by VAD status.** Patient survival estimated using unadjusted Kaplan-Meier methods. Ventricular assist device (VAD) status at time of transplant.

Figure HR 64: Patient survival among adult heart transplant recipients, 2014-2016, by VAD status. Patient survival estimated using unadjusted Kaplan-Meier methods. Ventricular assist device (VAD) status at time of transplant.

**Patient survival among adult heart transplant recipients, 2014-2016, by medical urgency.** Patient survival estimated using unadjusted Kaplan-Meier methods.

Figure HR 65: Patient survival among adult heart transplant recipients, 2014-2016, by medical urgency. Patient survival estimated using unadjusted Kaplan-Meier methods.

**Patient survival among adult heart transplant recipients, 2014-2016, by metropolitan vs. non-metropolitan recipient residence.** Patient survival estimated using unadjusted Kaplan-Meier methods.

Figure HR 66: Patient survival among adult heart transplant recipients, 2014-2016, by metropolitan vs. non-metropolitan recipient residence. Patient survival estimated using unadjusted Kaplan-Meier methods.

**Incidence of acute rejection by 1 year posttransplant among adult heart transplant recipients by age.** Only the first reported rejection event is counted. Cumulative incidence is estimated using the Kaplan-Meier method.

Figure HR 67: Incidence of acute rejection by 1 year posttransplant among adult heart transplant recipients by age. Only the first reported rejection event is counted. Cumulative incidence is estimated using the Kaplan-Meier method.

**Incidence of PTLD among adult heart transplant recipients by recipient EBV status at transplant, 2010-2016.** Cumulative incidence is estimated using the Kaplan-Meier method. PTLD is identified as a reported complication or cause of death on the OPTN Transplant Recipient Follow-up Form or the Posttransplant Malignancy Form as polymorphic PTLD, monomorphic PTLD, or Hodgkin's disease. Only the earliest date of PTLD diagnosis is considered. EBV, Epstein-Barr virus; PTLD, posttransplant lymphoproliferative disorder.

Figure HR 68: Incidence of PTLD among adult heart transplant recipients by recipient EBV status at transplant, 2010-2016. Cumulative incidence is estimated using the Kaplan-Meier method. PTLD is identified as a reported complication or cause of death on the OPTN Transplant Recipient Follow-up Form or the Posttransplant Malignancy Form as polymorphic PTLD, monomorphic PTLD, or Hodgkin’s disease. Only the earliest date of PTLD diagnosis is considered. EBV, Epstein-Barr virus; PTLD, posttransplant lymphoproliferative disorder.

**New pediatric candidates added to the heart transplant waiting list.** A new candidate is one who first joined the list during the given year, without having been listed in a previous year. Previously listed candidates who underwent transplant and subsequently relisted are considered new. Candidates listed at more than one center are counted once per listing. Active and inactive patients are included.

Figure HR 69: New pediatric candidates added to the heart transplant waiting list. A new candidate is one who first joined the list during the given year, without having been listed in a previous year. Previously listed candidates who underwent transplant and subsequently relisted are considered new. Candidates listed at more than one center are counted once per listing. Active and inactive patients are included.

**All pediatric candidates on the heart transplant waiting list.** Pediatric candidates listed at any time during the year. Candidates listed at more than one center are counted once per listing.

Figure HR 70: All pediatric candidates on the heart transplant waiting list. Pediatric candidates listed at any time during the year. Candidates listed at more than one center are counted once per listing.

**Distribution of pediatric candidates waiting for heart transplant by age.** Candidates waiting for transplant at any time in the given year. Candidates listed at more than one center are counted once per listing. Active and inactive candidates are included. Age is determined at the earliest of transplant, death, removal, or December 31 of the year.

Figure HR 71: Distribution of pediatric candidates waiting for heart transplant by age. Candidates waiting for transplant at any time in the given year. Candidates listed at more than one center are counted once per listing. Active and inactive candidates are included. Age is determined at the earliest of transplant, death, removal, or December 31 of the year.

**Distribution of pediatric candidates waiting for heart transplant by race.** Candidates waiting for transplant any time in the given year. Candidates listed at more than one center are counted once per listing. Active and inactive candidates are included.

Figure HR 72: Distribution of pediatric candidates waiting for heart transplant by race. Candidates waiting for transplant any time in the given year. Candidates listed at more than one center are counted once per listing. Active and inactive candidates are included.

**Distribution of pediatric candidates waiting for heart transplant by diagnosis.** Candidates waiting for transplant any time in the given year. Candidates listed at more than one center are counted once per listing. Active and inactive candidates are included. CM, cardiomyopathy.

Figure HR 73: Distribution of pediatric candidates waiting for heart transplant by diagnosis. Candidates waiting for transplant any time in the given year. Candidates listed at more than one center are counted once per listing. Active and inactive candidates are included. CM, cardiomyopathy.

**Distribution of pediatric candidates waiting for heart transplant by sex.** Candidates waiting for transplant any time in the given year. Candidates listed at more than one center are counted once per listing. Active and inactive patients are included.

Figure HR 74: Distribution of pediatric candidates waiting for heart transplant by sex. Candidates waiting for transplant any time in the given year. Candidates listed at more than one center are counted once per listing. Active and inactive patients are included.

**Distribution of pediatric candidates waiting for heart transplant by waiting time.** Candidates waiting for transplant any time in the given year. Candidates listed at more than one center are counted once per listing. Time on the waiting list is determined at the earliest of transplant, death, removal, or December 31 of the year. Active and inactive candidates are included.

Figure HR 75: Distribution of pediatric candidates waiting for heart transplant by waiting time. Candidates waiting for transplant any time in the given year. Candidates listed at more than one center are counted once per listing. Time on the waiting list is determined at the earliest of transplant, death, removal, or December 31 of the year. Active and inactive candidates are included.

**Distribution of pediatric candidates waiting for heart transplant by medical urgency.** Candidates waiting for transplant any time in the given year. Candidates listed at more than one center are counted once per listing. Medical urgency is determined at the earliest of transplant, death, removal, or December 31 of the year. Active and inactive patients are included.

Figure HR 76: Distribution of pediatric candidates waiting for heart transplant by medical urgency. Candidates waiting for transplant any time in the given year. Candidates listed at more than one center are counted once per listing. Medical urgency is determined at the earliest of transplant, death, removal, or December 31 of the year. Active and inactive patients are included.

**Three-year outcomes for newly listed pediatric candidates waiting for heart transplant, 2016-2018.** Pediatric candidates who joined the waiting list in 2016-2018. Pediatric candidates listed at more than one center are counted once per listing. Removed from list includes all reasons except transplant and death. DD, deceased donor.

Figure HR 77: Three-year outcomes for newly listed pediatric candidates waiting for heart transplant, 2016-2018. Pediatric candidates who joined the waiting list in 2016-2018. Pediatric candidates listed at more than one center are counted once per listing. Removed from list includes all reasons except transplant and death. DD, deceased donor.

**Overall deceased donor heart transplant rates among pediatric waitlist candidates.** Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of waiting in a given year. Individual listings are counted separately.

Figure HR 78: Overall deceased donor heart transplant rates among pediatric waitlist candidates. Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of waiting in a given year. Individual listings are counted separately.

**Deceased donor heart transplant rates among pediatric waitlist candidates by age.** Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of waiting in a given year. Individual listings are counted separately. Age is determined at the later of listing date or January 1 of the given year.

Figure HR 79: Deceased donor heart transplant rates among pediatric waitlist candidates by age. Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of waiting in a given year. Individual listings are counted separately. Age is determined at the later of listing date or January 1 of the given year.

**Deceased donor heart transplant rates among pediatric waitlist candidates by race.** Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of waiting in a given year. Individual listings are counted separately.

Figure HR 80: Deceased donor heart transplant rates among pediatric waitlist candidates by race. Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of waiting in a given year. Individual listings are counted separately.

**Deceased donor heart transplant rates among pediatric waitlist candidates by metropolitan vs. non-metropolitan residence.** Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of waiting in a given year. Individual listings are counted separately.

Figure HR 81: Deceased donor heart transplant rates among pediatric waitlist candidates by metropolitan vs. non-metropolitan residence. Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of waiting in a given year. Individual listings are counted separately.

**Overall pretransplant mortality rates among pediatric candidates waitlisted for heart.** Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Individual listings are counted separately.

Figure HR 82: Overall pretransplant mortality rates among pediatric candidates waitlisted for heart. Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Individual listings are counted separately.

**Pretransplant mortality rates among pediatric candidates waitlisted for heart transplant by age.** Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Individual listings are counted separately. Age is determined at the later of listing date or January 1 of the given year.

Figure HR 83: Pretransplant mortality rates among pediatric candidates waitlisted for heart transplant by age. Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Individual listings are counted separately. Age is determined at the later of listing date or January 1 of the given year.

**Pretransplant mortality rates among pediatric candidates waitlisted for heart transplant by race.** Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Individual listings are counted separately.

Figure HR 84: Pretransplant mortality rates among pediatric candidates waitlisted for heart transplant by race. Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Individual listings are counted separately.

**Pretransplant mortality rates among pediatrics waitlisted for heart transplant by diagnosis.** Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Individual listings are counted separately. CM, cardiomyopathy.

Figure HR 85: Pretransplant mortality rates among pediatrics waitlisted for heart transplant by diagnosis. Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Individual listings are counted separately. CM, cardiomyopathy.

**Pretransplant mortality rates among pediatrics waitlisted for heart transplant by medical urgency.** Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Individual listings are counted separately. Medical urgency is determined at the later of listing date or January 1 of the given year.

Figure HR 86: Pretransplant mortality rates among pediatrics waitlisted for heart transplant by medical urgency. Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Individual listings are counted separately. Medical urgency is determined at the later of listing date or January 1 of the given year.

**Pretransplant mortality rates among pediatric candidates waitlisted for heart transplant by metropolitan vs. non-metropolitan residence.** Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Individual listings are counted separately. Urban/rural determination is made using the RUCA (rural-urban commuting area) designation of the candidate's permanent zip code.

Figure HR 87: Pretransplant mortality rates among pediatric candidates waitlisted for heart transplant by metropolitan vs. non-metropolitan residence. Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Individual listings are counted separately. Urban/rural determination is made using the RUCA (rural-urban commuting area) designation of the candidate’s permanent zip code.

**Overall pediatric heart transplants.** All pediatric heart transplant recipients, including retransplant, and multiorgan recipients.

Figure HR 88: Overall pediatric heart transplants. All pediatric heart transplant recipients, including retransplant, and multiorgan recipients.

**Pediatric heart transplants by recipient age.** All pediatric heart transplant recipients, including retransplant, and multiorgan recipients.

Figure HR 89: Pediatric heart transplants by recipient age. All pediatric heart transplant recipients, including retransplant, and multiorgan recipients.

**Pediatric heart transplants by sex.** All pediatric heart transplant recipients, including retransplant, and multiorgan recipients.

Figure HR 90: Pediatric heart transplants by sex. All pediatric heart transplant recipients, including retransplant, and multiorgan recipients.

**Pediatric heart transplants by race.** All pediatric heart transplant recipients, including retransplant, and multiorgan recipients.

Figure HR 91: Pediatric heart transplants by race. All pediatric heart transplant recipients, including retransplant, and multiorgan recipients.

**Pediatric heart transplants by diagnosis.** All pediatric heart transplant recipients, including retransplant, and multiorgan recipients. CM, cardiomyopathy.

Figure HR 92: Pediatric heart transplants by diagnosis. All pediatric heart transplant recipients, including retransplant, and multiorgan recipients. CM, cardiomyopathy.

**Pediatric heart transplants by medical urgency.** All pediatric heart transplant recipients, including retransplant, and multiorgan recipients. The OPTN heart allocation policy changed the status groups in October 2018.

Figure HR 93: Pediatric heart transplants by medical urgency. All pediatric heart transplant recipients, including retransplant, and multiorgan recipients. The OPTN heart allocation policy changed the status groups in October 2018.

Figure HR 94: Induction agent use in pediatric heart transplant recipients. Immunosuppression at transplant reported to the OPTN.

**Immunosuppression regimen use in pediatric heart transplant recipients.** Immunosuppression regimen at transplant reported to the OPTN. Tac, tacrolimus. MMF, all mycophenolate agents.

Figure HR 95: Immunosuppression regimen use in pediatric heart transplant recipients. Immunosuppression regimen at transplant reported to the OPTN. Tac, tacrolimus. MMF, all mycophenolate agents.

**Incidence of acute rejection by 1 year posttransplant among pediatric heart transplant recipients by age.** Only the first reported rejection event is counted. Cumulative incidence is estimated using the Kaplan-Meier method.

Figure HR 96: Incidence of acute rejection by 1 year posttransplant among pediatric heart transplant recipients by age. Only the first reported rejection event is counted. Cumulative incidence is estimated using the Kaplan-Meier method.

$**Incidence of PTLD among pediatric heart transplant recipients by recipient EBV status at transplant, 2010-2016.** Cumulative incidence is estimated using the Kaplan-Meier method. PTLD is identified as a reported complication or cause of death on the OPTN Transplant Recipient Follow-up Form or on the Posttransplant Malignancy Form as polymorphic PTLD, monomorphic PTLD, or Hodgkin's disease. Only the earliest date of PTLD diagnosis is considered. EBV, Epstein-Barr virus. PTLD, posttransplant lymphoproliferative disorder.$

Figure HR 97: Incidence of PTLD among pediatric heart transplant recipients by recipient EBV status at transplant, 2010-2016. Cumulative incidence is estimated using the Kaplan-Meier method. PTLD is identified as a reported complication or cause of death on the OPTN Transplant Recipient Follow-up Form or on the Posttransplant Malignancy Form as polymorphic PTLD, monomorphic PTLD, or Hodgkin’s disease. Only the earliest date of PTLD diagnosis is considered. EBV, Epstein-Barr virus. PTLD, posttransplant lymphoproliferative disorder.

**Patient death among pediatric heart transplant recipients.** All pediatric recipients of deceased donor hearts, including multiorgan transplants. Estimates are unadjusted, computed using unadjusted Kaplan-Meier methods.

Figure HR 98: Patient death among pediatric heart transplant recipients. All pediatric recipients of deceased donor hearts, including multiorgan transplants. Estimates are unadjusted, computed using unadjusted Kaplan-Meier methods.

**Overall patient survival among pediatric deceased donor heart transplant recipients, 2014-2016.** Recipient survival estimated using unadjusted Kaplan-Meier methods.

Figure HR 99: Overall patient survival among pediatric deceased donor heart transplant recipients, 2014-2016. Recipient survival estimated using unadjusted Kaplan-Meier methods.

**Patient survival among pediatric deceased donor heart transplant recipients, 2014-2016, by recipient age.** Recipient survival estimated using unadjusted Kaplan-Meier methods.

Figure HR 100: Patient survival among pediatric deceased donor heart transplant recipients, 2014-2016, by recipient age. Recipient survival estimated using unadjusted Kaplan-Meier methods.

Characteristic	2011 N	2011 Percent	2021 N	2021 Percent
Age (years)
18-34 years	320	11.1	365	11.9
35-49	651	22.6	680	22.1
50-64	1,427	49.5	1,465	47.7
65+	487	16.9	563	18.3
Sex
Male	2,146	74.4	2,340	76.1
Female	739	25.6	733	23.9
Race
White	1,996	69.2	1,732	56.4
Black	612	21.2	906	29.5
Asian	62	2.1	93	3.0
Hispanic	187	6.5	313	10.2
Other	28	1.0	29	0.9
Geography
Metropolitan	2,395	83.0	2,613	85.0
Non-metropolitan	469	16.3	430	14.0
Missing	21	0.7	30	1.0
Miles between candidate to center
<50 miles	1,676	58.1	1,867	60.8
50-<100	477	16.5	479	15.6
100-<150	269	9.3	296	9.6
150-<250	247	8.6	216	7.0
250+	198	6.9	191	6.2
Missing	18	0.6	24	0.8
All candidates
All candidates	2,885	100.0	3,073	100.0

Characteristic	2011 N	2011 Percent	2021 N	2021 Percent
Diagnosis
Coronary artery disease	1,088	37.7	855	27.8
Cardiomyopathy	1,429	49.5	1,826	59.4
Congenital disease	151	5.2	167	5.4
Valvular disease	54	1.9	31	1.0
Other/unknown	157	5.4	194	6.3
NA	6	0.2	0	0
Blood Type
A	923	32.0	821	26.7
AB	61	2.1	43	1.4
B	305	10.6	311	10.1
O	1,596	55.3	1,898	61.8
VAD status at listing
No VAD	2,318	80.3	1,964	63.9
VAD	535	18.5	1,096	35.7
Missing	32	1.1	13	0.4
Urgency status for heart candidates
Status 1A	202	7.0	0	0
Status 1B	907	31.4	0	0
Status 2	963	33.4	0	0
Temporarily inactive	813	28.2	669	21.8
Adult Status 1	0	0	16	0.5
Adult Status 2	0	0	118	3.8
Adult Status 3	0	0	156	5.1
Adult Status 4	0	0	1,419	46.2
Adult Status 5	0	0	134	4.4
Adult Status 6	0	0	560	18.2
Adults listed under pediatric status	0	0	1	0.0
All candidates
All candidates	2,885	100.0	3,073	100.0

Characteristic	2011 N	2011 Percent	2021 N	2021 Percent
Previous transplant
No prior transplant	2,770	96.0	2,982	97.0
Prior transplant	115	4.0	91	3.0
Waiting time
<90 days	541	18.8	594	19.3
3-<6 months	384	13.3	340	11.1
6-<12 months	518	18.0	581	18.9
1-<2 years	628	21.8	604	19.7
2+ years	814	28.2	954	31.0
All candidates
All candidates	2,885	100.0	3,073	100.0

Waiting list state	2019	2020	2021
Waiting list state
Patients at start of year	3,476	3,386	3,146
Patients added during year	4,087	4,000	4,373
Patients removed during year	4,177	4,240	4,446
Patients at end of year	3,386	3,146	3,073

Removal reason	2019	2020	2021
Removal reason
Deceased donor transplant	3,075	3,240	3,354
Patient died	177	191	210
Patient refused transplant	25	19	23
Improved, transplant not needed	163	147	198
Too sick for transplant	280	243	252
Other	457	400	409

Life support type	2018 N	2018 Percent	2021 N	2021 Percent
Life support type
Any life support	2,431	81.9	2,574	76.3
Left ventricular assist device	1,307	44.1	1,060	31.4
Intravenous inotropes	1,015	34.2	1,268	37.6
Intra-aortic balloon pump	278	9.4	930	27.6
Right ventricular assist device	46	1.6	57	1.7
Extra corporeal membrane oxygenation	58	2.0	229	6.8
Total artificial heart	32	1.1	13	0.4
Ventilator	34	1.1	78	2.3
Inhaled NO	5	0.2	14	0.4
Prostaglandins	5	0.2	5	0.1

Life support type	2016 N	2016 Percent	2021 N	2021 Percent
Life support type
Any life support	341	76.6	332	67.8
Left ventricular assist device	102	22.9	168	34.3
Intravenous inotropes	236	53.0	195	39.8
Intra-aortic balloon pump	1	0.2	4	0.8
Right ventricular assist device	14	3.1	28	5.7
Extra corporeal membrane oxygenation	18	4.0	20	4.1
Total artificial heart	0	0	1	0.2
Ventilator	78	17.5	36	7.3
Inhaled NO	6	1.3	6	1.2
Prostaglandins	18	4.0	8	1.6

**Table HR 7:** **Demographic characteristics of adult heart transplant recipients, 2011 and 2021.** Heart transplant recipients, including retransplants. Distance is computed from recipient's home zip code to the transplant center.
Characteristic	2011 N	2011 Percent	2021 N	2021 Percent
Recipient age (years)
18-34 years	224	11.3	385	11.4
35-49	391	19.8	620	18.4
50-64	1,024	51.9	1,636	48.5
65+	335	17.0	731	21.7
Sex
Male	1,420	71.9	2,484	73.7
Female	554	28.1	888	26.3
Race
White	1,340	67.9	1,986	58.9
Black	409	20.7	842	25.0
Asian	59	3.0	158	4.7
Hispanic	157	8.0	354	10.5
Other	9	0.5	32	0.9
Insurance
Private	971	49.2	1,504	44.6
Medicare	731	37.0	1,187	35.2
Medicaid	194	9.8	485	14.4
Other/unknown	78	4.0	196	5.8
Geography
Metropolitan	1,675	84.9	2,824	83.7
Non-metropolitan	273	13.8	446	13.2
Missing	26	1.3	102	3.0
Miles between recipient to center
<50 miles	1,219	61.8	1,999	59.3
50-<100	313	15.9	545	16.2
100-<150	182	9.2	275	8.2
150-<250	144	7.3	261	7.7
250+	98	5.0	199	5.9
Missing	18	0.9	93	2.8
All recipients
All recipients	1,974	100.0	3,372	100.0

**Table HR 17:** **Clinical characteristics of pediatric heart transplant recipients, 2011 and 2021.** Pediatric heart transplant recipients, including retransplants. Collection of calculated PRA (cPRA) began March 31, 2015. Prior to that, measured PRA values were used. CM, cardiomyopathy; VAD, ventricular assist device.
Characteristic	2011 N	2011 Percent	2021 N	2021 Percent
Diagnosis
Congenital defect	161	42.9	247	50.4
Idiopathic dilated CM	117	31.2	113	23.1
Familial dilated CM	20	5.3	31	6.3
Idiopathic restricted CM	12	3.2	18	3.7
Myocarditis	19	5.1	6	1.2
Other/unknown	46	12.3	75	15.3
Blood Type
A	148	39.5	175	35.7
AB	19	5.1	23	4.7
B	48	12.8	66	13.5
O	160	42.7	226	46.1
VAD at transplant
VAD	71	18.9	176	35.9
No VAD	304	81.1	312	63.7
Missing	0	0	2	0.4
CPRA
<1%	170	45.3	249	50.8
1-<20%	61	16.3	42	8.6
20-<80%	77	20.5	53	10.8
80-<98%	16	4.3	18	3.7
98-100%	7	1.9	5	1.0
Missing	44	11.7	123	25.1
Urgency status for heart recipients
Status 1A	335	89.3	401	81.8
Status 1B	26	6.9	82	16.7
Status 2	14	3.7	7	1.4
All recipients
All recipients	375	100.0	490	100.0