Daniel Ahn, MD, BS, discusses the need for pediatric heart transplant policy reform

In a recent interview for Contemporary Pediatrics, Daniel Jaechul Ahn, MD, BS, resident in surgery at Stanford Medicine, discussed the systemic issues and “allocational inefficiencies” currently plaguing the pediatric heart transplant system. Ahn argued that the existing 3-status categorization used by the Organ Procurement and Transplantation Network (OPTN) fails to accurately prioritize patients based on their actual medical urgency.^1,2

According to Ahn, the current system is overly simplistic, leading to approximately 60% of children being listed at the highest priority upon initial listing. This creates a “first-come, first-served” dynamic rather than one based on clinical need.

Because the categories are so broad, physicians often feel systemic pressure to request status exceptions to advocate for their patients. These exceptions are frequently sought for lower-risk patients because the standard criteria do not capture the unique vulnerabilities of pediatric candidates, such as the extreme wait times—sometimes exceeding a year—associated with specific blood types and weights.

Ahn’s research indicated that a hypothetical system without any exceptions would actually be more accurate at predicting waitlist mortality than the current one. He clarified, however, that the goal is not to eliminate exceptions entirely, as no algorithm is perfect. Instead, he views the high volume of exception requests as a symptom of an underlying problem: the lack of a sophisticated, continuous medical urgency score. He pointed to the success of laboratory-based scores in liver and adult heart allocation as a model for what is needed in pediatrics.

To resolve these inefficiencies and the “overcrowding” of high-priority statuses, Ahn and his co-authors advocate for the following:

• Moving away from the 3-status system toward a continuous score based on objective clinical data
• Improved data collection, as the OPTN currently does not collect the same level of granular data for children as it does for adults, which is a necessary first step for developing a more accurate allocation algorithm
• Structural review, as while the creation of the National Heart Review Board in 2021 was intended to help, Ahn noted it failed to improve survival alignment because it maintained the flawed 3-status structure

Ultimately, Ahn emphasized that while waitlist mortality has improved over decades—dropping from more than 20% to approximately 12.5%—it remains high. He believes a “watershed moment” in pediatric transplant will occur only when the system moves toward a data-driven medical urgency score that ensures donor hearts go to the children who need them most in a fair and efficient manner.

References

1. Ongoing problems with kids’ heart transplant waitlists found in Stanford Medicine-led studies. News release. Stanford Medicine. March 4, 2026. Accessed March 10, 2026. https://www.eurekalert.org/news-releases/1118781
2. Power A, Sweat KR, Roth A, et al. Contemporary pediatric heart transplant waitlist mortality. Journal of the American College of Cardiology. 2026;84(7). doi:10.1016/j.jacc.2026.01.052