OBJECTIVES:Allocation out-of-sequence (AOOS) is an allocation pathway that allows organ procurement organizations (OPOs) to bypass the standard match-run sequence to expedite organ placement and avoid organ wastage amidst donor, recipient, or logistical constraints. Amidst increasing use of AOOS in recent years, we sought to characterize its impact on lung utilization in the contemporary era. METHODS:We performed a retrospective analysis using United Network for Organ Sharing data from June 2021 to December 2024 to examine the association between OPO-level AOOS and lung nonuse. RESULTS:Among 10,350 lung donors, 931 (9.0%) were allocated out-of-sequence, with OPO-level rates of AOOS ranging from 1.2% to 28.9%. Observed-to-expected lung yield ratios were comparable across OPOs stratified by AOOS use, with no significant difference among low-, medium-, and high-AOOS groups (0.96 vs 0.97 vs 0.92; p=0.728). Among 20,462 individual lungs recovered for transplantation, 2,003 (9.8%) ultimately not used. After adjusting for donor characteristics and temporal trends, AOOS was not significantly associated with lung nonuse (incidence rate ratio 1.00, 95% confidence interval 0.94-1.06, p=0.883). CONCLUSION:These findings indicate that further revision of lung allocation policy is required to optimize lung utilization and mitigate use of alternative allocation pathways.

Introduction Donation after circulatory death (DCD) heart transplantation demonstrates preserved conventional ventricular and valvular function through 1-year follow-up. However, strain imaging identifies subtle but persistent abnormalities in myocardial deformation, suggesting distinct myocardial recovery patterns and possible subclinical ischemia-related graft injury after DCD transplantation. Methods This single-center retrospective cohort study compared DCD and Donation after Brain Death (DBD) heart transplant recipients from 2016 to 2022, at 1-, 3-, 6-, and 12-month post-transplantation. Conventional echocardiographic variables, valvular function, and speckle-tracking strain analysis, including left ventricular global longitudinal strain (LVGLS), right ventricular global longitudinal strain (RVGLS), and right ventricular free wall strain (RVFWS) were compared between DCD and DBD recipients. Multivariable linear regression, chi-squared/Fisher Exact testing, and linear mixed-effects modeling were used to evaluate longitudinal outcomes. Exploratory multivariable analyses evaluated associations between GLS and perioperative variables. Results Fifty-one DCD and 201 DBD hearts were transplanted. Conventional echocardiography demonstrated no significant differences in LVEF or presence of valvular dysfunction at any timepoint. The treatment group-by-time interaction was not significant (p = 0.566). However, DCD recipients demonstrated significantly less negative LVGLS at 3 months (−13.9±3.54 vs −18.0±3.19, p<0.0001) and 12 months (−16.0±3.08 vs −18.1±3.17, p = 0.0007). Early RV dysfunction was also observed in DCD recipients at 3 months by RVGLS and RVFWS analysis. Longitudinal mixed-effects modeling demonstrated a significant donor type-by-timepoint interaction for GLS (p = 0.034). Exploratory multivariable modeling demonstrated that DCD donor status (β=1.52, p = 0.021) and total ischemic interval (β=0.0057, p = 0.034) remained independently associated with impaired GLS. Conclusion DCD heart transplantation demonstrates preserved conventional ventricular and valvular function through 1-year follow-up. However, strain imaging identifies subtle but persistent abnormalities in myocardial deformation, suggesting distinct myocardial recovery patterns and possible subclinical ischemia-related graft injury after DCD transplantation.

Background The Ross procedure (RP) is technically complex but offers superior hemodynamics and improved long-term survival compared to prosthetic aortic valve replacement, particularly in young adults. Despite these advantages, widespread adoption has been limited by concerns regarding technical complexity, operative risk, and the learning curve associated with Ross program development. This study evaluates the early experience of the first 50 RPs performed by a lead surgeon compared to propensity-matched surgical aortic valve replacement (SAVR). Methods The RP has historically been criticized for its higher operative complexity and perceived risk during the learning curve. To address this, we compared the first 50 RPs performed by a lead surgeon within a structured Ross program to 50 propensity-matched isolated SAVR patients. The primary outcome was 30-day mortality, while secondary outcomes included perioperative events, operative times, and valve hemodynamics. Results The Ross cohort was younger (42 vs 53 years, P < .01) and had lower rates of hypertension (40.0% vs 62.1%, P = .005). Twenty six cases (52%) were performed with structured two-attending mentorship. After propensity matching, no 30-day mortality was observed in either group. Ross procedures had longer cross-clamp times (183 [161-211] vs 83 [66-103] min, P < .01) but achieved lower mean aortic valve gradients (4 [3-4] vs 9 [7-12] mm Hg, P < .01) with similar lengths of stay (6 [5-7] days vs 6 [5-7] days, P = .81). Although several important perioperative technical events occurred during the Ross experience, including unplanned coronary bypass grafting and reoperation for autograft dysfunction, these events were recognized promptly and managed successfully without excess mortality or major morbidity. Conclusions Our early experience suggests that establishment of a modern Ross program is feasible with excellent early outcomes when supported by careful patient selection, structured mentorship, operative standardization, multimodality imaging, and robust institutional infrastructure. Importantly, transparent reporting of technical complications, lessons learned, and evolving perioperative strategies during the learning curve may help guide safe dissemination of the Ross procedure to additional centers.

Background:The Impella 5.5 is a temporary mechanical circulatory support device consisting of a microaxial pump that unloads the left ventricle and provides hemodynamic support, but data in bypass grafting (CABG) are limited. Methods:We conducted a single-center retrospective case series of adult patients who underwent isolated CABG with perioperative Impella 5.5 support between July 2020 and May 2024. Perioperative support was defined as implantation before separation from cardiopulmonary bypass (CPB) or immediately after CPB wean. Patients with prior mechanical circulatory support, preoperative Impella as the primary indication, or concomitant/reoperative cardiac surgery were excluded. Clinical characteristics, procedural details, and early outcomes were obtained from the electronic medical record. Results:Sixteen patients met inclusion criteria. Median age was 59 years (range: 51-90 years), 93.8% were male, and 75.0% self-identified as White. Median preoperative LVEF was 20.5% (IQR: 15-25). Median Impella support duration was 6.97 days (IQR: 3.7-20.3 days). The device was implanted before CPB separation in 8 patients (50.0%) and immediately after CPB wean in 8 (50.0%); 93.8% were implanted via a right axillary graft. Thirteen patients (81.3%) were successfully weaned, and 1 patient (6.3%) was bridged to HeartMate 3. Two patients (12.5%) died before device explantation, and 1 additional patient died later during the same hospitalization after explantation, yielding an overall in-hospital mortality of 3 patients (18.8%). Rhythm complications occurred in 9 patients (56.3%), most commonly rapid atrial fibrillation (31.3%); sustained ventricular tachycardia occurred in 2 (12.5%), with 1 death. One intrapump thrombus required device exchange; no major bleeding or access-site infections occurred. Conclusion:Impella 5.5 support in high-risk CABG with LV dysfunction was feasible in selected patients and may serve as an adjunct to surgical revascularization.

OBJECTIVES:The use of in situ internal thoracic artery (ITA) grafts ipsilateral to upper extremity arterio-venous fistulas (UE-AVFs) during coronary artery bypass grafting (CABG) in dialysis-dependent patients raises concerns of coronary steal and compromised graft perfusion. However, the clinical significance of ITA-AVF laterality remains uncertain. METHODS:We retrospectively analysed dialysis-dependent patients who underwent CABG between February 2015 and December 2023 at 2 institutions. Patients with non-UE-AVF access, total vein grafting, or composite vein-artery configurations were excluded. The final cohort (N = 122) was divided into 2 groups: ipsilateral in situ ITA grafts (N = 66) and contralateral in situ or free ITA grafts (N = 56). The primary outcome was the incidence of major adverse cardiovascular and cerebrovascular events (MACCE); secondary outcomes included perioperative complications, haemodialysis-induced ischaemia, and 3-year survival. RESULTS:Baseline and operative characteristics were largely comparable between groups. Perioperative outcomes, including surgical site infection, 30-day mortality, and prolonged ventilation, showed no significant differences. Over a median follow-up of 2.4 years, MACCE occurred in 44% of patients (39% ipsilateral vs 50% contralateral/free ITA; P = .24), with no significant differences in 3-year mortality (29% vs 21%; P = .352). Multivariable analyses showed no association between ITA-AVF laterality and MACCE (adjusted odds ratio 0.68, P = .31) or 3-year mortality (adjusted hazard ratio 1.56, P = .291). CONCLUSIONS:In this modestly sized retrospective cohort, ipsilateral in situ ITA grafting was not associated with significantly worse perioperative or long-term outcomes. Our findings should be interpreted as hypothesis-generating, and larger multicentre studies are needed to more definitively evaluate the safety of this grafting strategy in dialysis-dependent patients with UE-AVFs.

Background: The Composite Allocation Score (CAS) was intended to optimize net benefit of lung transplantation, balancing medical urgency with anticipated posttransplant survival while broadening geographic distribution. This system may disadvantage critically ill patients in whom urgency may outweigh projected survival. Research Question: What are the waitlist and posttransplant outcomes for patients in the ICU within the first year of the CAS era? Study Design and Methods: Patients in the ICU in the Organ Procurement and Transplantation Network registry listed for or undergoing primary isolated lung transplantation between March 9, 2022, and March 9, 2024, were included and stratified into before and after the March 9, 2023, CAS system change. Survival between eras was compared using Cox regression and Kaplan-Meier curves for transplant recipients as well as waitlisted patients. Results: Eight hundred fifty-one of 6,052 candidates (14%) and 998 of 5,716 recipients (18%) were in the ICU during the study period. In the CAS era, transplantation rate (334 of 368 [90.8%] vs 362 of 483 [75%]) was higher and waitlist duration was shorter (12 days vs 18 days; P < .001 for both). Waitlist mortality (16 of 483 [3%] vs 12 of 368 [3%]; P = .97) and posttransplant 30-day mortality (15 of 453 [3%] vs 17 of 545 [3%]; P = .86) was similar in lung allocation score vs CAS eras. The primary outcome, 6-month mortality, also was similar in unadjusted analysis (36 of 453 [8%] vs 41 of 545 [8%]; P = .80). Although adjusted analysis showed a higher risk in the CAS era (adjusted hazard ratio [aHR], 1.65 [95% CI, 1.01-2.67]; P = .04), sensitivity analysis excluding 69 patients listed before CAS implementation but who underwent transplantation after CAS implementation did not demonstrate significant mortality (aHR, 1.61 [95% CI, 0.98-2.67]; P = .06). Other posttransplant outcomes of acute rejection, extracorporeal membrane oxygenation requirement, ventilator requirement, and posttransplant length of stay were comparable between eras (P > .05). Interpretation: Our results suggest that CAS implementation has increased lung transplantation rates and decreased waitlist time with no meaningful differences in primary and secondary outcomes between the eras. Continued reassessment of this continuous distribution policy is required to understand implications for high-acuity patients.

BACKGROUND STS and Vizient each produce rating systems for cardiac surgery performance. At our institution, during a similar timeframe and for nominally similar cohorts, STS ratings indicated exemplary performance while Vizient suggested worse than expected performance. We hypothesized that these discordant quality signals were driven by methodological differences in how each platform defines cohorts, captures data, adjusts risk, and measures outcomes. METHODS We conducted a single-institution, 12-month retrospective comparison of procedures categorized as isolated coronary artery bypass grafting (CABG) by either STS or Vizient. We compared data sources, patient cohort definitions, observation periods, risk modeling, and outcome definitions, and performed chart review of cases unique to either database. RESULTS STS identified 414 and Vizient 407 patients in their isolated CABG cohorts. Of these, 398 patients were shared, while 16 were unique to STS and 9 to Vizient. STS and Vizient recorded discrepant mortality counts (9 vs 8 deaths, respectively). Chart reviews revealed discordant operative procedure classifications and inconsistent capture of perioperative events between systems. STS relies on audited clinical registry data, clinically-defined patient cohorts and risk factors, peer-reviewed risk models and measures, and multi-year rolling data windows. Vizient uses administrative claims data and associated risk-adjustment variables and outcomes, proprietary methodologies, and shorter reporting cycles. CONCLUSIONS Discordant assessments of cardiac surgery performance by STS and Vizient quality ratings reflect multiple methodological differences. Understanding these differences is essential for assessing the credibility of these two performance rating systems, reconciling conflicting reports, educating hospital leadership and the public, and guiding evidence-based quality improvement.

BACKGROUND:Prosthesis-patient mismatch (PPM) impacts surgical aortic valve replacement outcomes, with known associations with adverse clinical consequences. However, contemporary understanding of PPM's clinical implications, trends, and predictive factors remains limited. METHODS:This multi-institutional study included all patients undergoing surgical aortic valve replacement between 2002 and 2023. PPM was calculated using effective orifice area indexed to body surface area (EOAi), categorized as moderate (EOAi ≤0.85 cm2/m2) or severe (EOAi ≤0.65 cm2/m2), with modified criteria for patients with body mass index ≥30 kg/m2 according to Valve Academic Research Consortium 3 guidelines. Clinical outcomes and predictors were assessed using Kaplan-Meier and multivariable analysis. RESULTS:Among 10,607 surgical aortic valve replacement patients, 8102 (76%) had no PPM, 2333 (22%) had moderate PPM, and 172 (2%) had severe PPM. PPM prevalence declined over the last decade (31% to 18%, P < .05), coinciding with larger prosthetic valves (size 23 [SD, 2] mm to 24 [SD, 2] mm, P < .05) and increased annular enlargement (2.4% to 6.0%, P < .05). PPM was associated with higher 30-day mortality (odds ratio, 1.46; 95% CI 1.13-1.88; P < .05) and reduced long-term survival. Age- and sex-stratified analysis revealed a stronger association between advanced age and PPM risk in women compared with men (odds ratio, 2.31 vs 1.66 for age >74 vs <65 years; both P < .05). CONCLUSIONS:PPM prevalence has declined through technical improvements and evolving patient selection but remains a significant predictor of adverse outcomes. The pronounced risk in older female patients highlights the need for targeted surgical strategies, including careful prosthesis selection and consideration of annular enlargement in high-risk groups.

BACKGROUND:Valve-sparing aortic root replacement (VSRR) provides durable outcomes when successful; however, limited data exist on the incidence or consequences of repeated intraoperative repair attempts or failure. This study evaluated outcomes of aortic root replacement when valve preservation was initially intended, irrespective of the eventual procedural success. METHODS:We retrospectively reviewed patients who underwent aortic root replacement (VSRR or Bentall) between 2002 and 2023, excluding those with aortic stenosis, previous aortic valve replacement, endocarditis, or partial root replacement. Patients were categorized as single-clamp VSRR (S-VSRR, n = 251), multiple-clamp VSRR (M-VSRR, n = 16), failed VSRR (F-VSRR, n = 10), and primary Bentall (n = 548). RESULTS:VSRR was unsuccessful, or required multiple crossclamp attempts, in 9.4% of cases. Failure occurred in 1.0% of aneurysm and 2.5% of dissection cases (P = .28). Bentall patients were older (58 ± 14 years) than S-VSRR (48.2 ± 14.2 years) and M-VSRR (48 ± 13 years; P < .01). Preoperative severe aortic regurgitation (AR) was most frequent in F-VSRR (70%). Preservation succeeded in 83% with moderate-to-severe AR versus 89% with none-to-mild AR. Leaflet repair was more common in M-VSRR (43.8%) than S-VSRR (19.5%; P = .02). In unadjusted analysis, F-VSRR was associated with more bleeding-related reoperations and longer intensive care unit and hospital stays. At follow-up, 85.6% of S-VSRR and 68.7% of M-VSRR had none-to-mild AR. Mortality and reoperation rates were low across groups. CONCLUSIONS:VSRR was technically challenging or unsuccessful in about 10% of cases, especially with advanced AR. Although midterm survival and valve durability were comparable, these patients may experience greater perioperative morbidity, underscoring the need for careful patient selection and intraoperative judgement.

INTRODUCTION:Obesity and metabolic syndrome are common in liver transplant recipients and cause adverse health outcomes. We aimed to elicit patients' perceived barriers and needs for post-transplant weight loss. METHODS:A convergent mixed methods approach was used to assess attitudes, needs, and barriers to using resources for weight loss. A cross-sectional survey was administered to liver transplant recipients with a body mass index > 25, and focus groups expanded information on topics of interest. Descriptive statistics, Student's t-test, and Wilcoxon rank-sum were used to analyze the survey results, and reflexive thematic analysis was performed for focus groups. RESULTS:Fifty-three respondents (63.5% male; 88.4% Caucasian; median body mass index 30.7 [27.5, 33.7]) completed the survey (11.9% response rate). The majority (73.6%) believed obesity adversely affected liver grafts. Most patients tried weight loss lifestyle changes (diet modification [86.8%] and exercise [71.7%]). Factors negatively affecting weight management included immunosuppression (49.1%) and fatigue (54.7%). Of the respondents, 42.3% and 18% were likely to consider weight-loss medication and surgery, respectively. Potential liver damage from weight-loss medications (84.9%), medication side effects (60.4%), complications from bariatric surgery (47.1%), and surgery's impact on the transplanted liver (45.2%) were major concerns. Patients were motivated by the care of their transplanted organ when pursuing weight loss and were concerned about interventions that may damage their transplanted liver. Transplant-specific challenges (impact of emotions through the transplant process, physical limitations, and support from peers and health care personnel) were recurring themes. CONCLUSIONS:Post-transplant patients were largely motivated to lose weight to care for their new liver and concerned about liver damage and side effects when considering medical and surgical weight-loss interventions.

Background We evaluated the association between race/ethnicity and failure to rescue (FTR) following lung transplantation. Methods We conducted a retrospective cohort study of 34,184 patients undergoing primary lung transplantation (2006–2024). Race/ethnicity was categorized as non-Hispanic White (81.3%), non-Hispanic Black (9.5%), and Hispanic (9.1%). The primary outcome was FTR. Logistic regression identified predictors of FTR, while Cox proportional hazards models assessed the association between race/ethnicity and outcomes. Results Black patients experienced the highest rates of postoperative complications (26.3%) compared to non-Hispanic White (17.9%) and Hispanic patients (19.6%) (p < 0.001). Mortality rate was also highest among Black patients (6.8%) compared to White (5.0%) and Hispanic patients (4.8%) (p <0.001). However, race/ethnicity was not independently associated with FTR. Risk factors for FTR included dialysis at transplant (OR 2.05, 95% CI: 1.28–3.29, p=0.003), double lung transplant (OR 1.30, 95% CI: 1.09–1.56, p=0.004), and prolonged ischemic time (OR 1.05, 95% CI: 1.02–1.08, p=0.001). Conclusions While Black patients experienced higher complication and mortality rates, race/ethnicity was not independently linked to FTR after lung transplantation.

BACKGROUND:Postoperative atrial fibrillation (POAF) is the most common complication after cardiac surgery, occurring in 30%-50% of patients. Although previous studies have suggested a protective benefit from pericardiotomy and prophylactic amiodarone, these practices have not been widely adopted. The Pericardiotomy and Amiodarone for Prophylaxis against Postoperative Atrial Fibrillation (PAPPA) trial was designed to compare the incidence of POAF in cardiac surgery patients who receive a systematic pharmacosurgical prevention strategy vs standard of care. METHODS:In this prospective, propensity-matched, historically controlled trial, adult patients undergoing isolated coronary artery bypass grafting between 2022 and 2024 received a standardized pharmacosurgical intervention including posterior pericardiotomy and low-dose amiodarone. Outcomes in these patients were compared against those in a population of propensity-matched historical controls who underwent isolated coronary artery bypass grafting between 2019 and 2021. The primary endpoint was POAF incidence. RESULTS:A total of 204 patients received the treatment protocol and were compared with 902 historical controls; 1:1 propensity matching generated 171 (84%) balanced pairs. The incidence of POAF was significantly lower in the treatment group compared to matched controls (18.1% vs 31.5%, P = .004). There was no statistically significant difference in the incidence of postoperative heart block between the 2 groups (0.6% vs 1.8%, P = .6228). However, fewer patients in the treatment group were discharged on anticoagulants (8.7% vs 14%, P = .1257). No significant differences were observed in 30-day mortality (0.6% in both groups, P > .99) or stroke rates (0.6% vs 1.2%, P = .562). CONCLUSIONS:In adults undergoing cardiac surgery, standardized pharmacosurgical prophylaxis including posterior pericardiotomy and low-dose amiodarone was associated with significantly lower incidence of POAF.

Background:Liver transplantation (LT) is the standard treatment for liver failure secondary to alcohol-associated liver disease, but limited literature and best practices exist for post-LT treatment of alcohol use disorder (AUD). This study explores current AUD management practices and providers' perceived barriers to effective post-LT AUD management. Methods:A 45-item survey on post-LT AUD treatment practices was distributed to members of the American Society of Transplant Surgeons, the Association of Consult/Liaison Psychiatry Transplant Special Interest Group, and both the American Society of Transplantation's Liver and Intestine Community of Practice and Psychosocial and Ethics Community of Practice discussion boards, between December 2021 and April 2022. Univariate analysis of categorical variables was performed using the chi-square test. Data were analyzed using center volume tertiles, country region, and provider professional activity. Results:Two hundred thirty-two respondents from 70 LT centers across all 11 United Network for Organ Sharing regions completed the survey. Half of the them were attending physicians and 16.4% were nurse coordinators. Most centers (84%) aimed for alcohol abstinence for all post-LT patients. Perceived barriers to AUD treatment efficacy included ongoing desire to drink (18%), denial about alcohol misuse (14.9%), and lack of posttransplant support (14%). Additionally, 62.1% of centers had no policy for prescribing medication-assisted therapy to treat AUD, and 32.7% of centers reported no center-level changes in AUD care. Providers identified primary needs as hiring additional mental health professionals (30.8%), dedicating specific staff to AUD care (24.7%), and standardizing psychiatric/psychological care in transplant clinics (17.2%). Conclusions:Despite the increasing volume of LT for alcohol-associated liver disease, significant perceived barriers to effective AUD treatment remain.

Objective: Telehealth preoperative evaluations have been shown to improve access to care, reduce appointment cancellations, and support efficient procedural planning across multiple surgical subspecialties. However, few studies have assessed the safety and efficacy in patients undergoing elective cardiac surgery. Methods: We conducted a retrospective multi-institutional cohort study comparing procedural and postoperative outcomes for patients who had telehealth versus in-person preoperative evaluations for elective cardiac surgery between March 1, 2020, and March 1, 2021. Primary outcome was 1-year mortality assessed using Kaplan-Meier curves and multivariable Cox regression. Secondary outcomes of procedural duration, reoperations, readmission, deep vein thrombosis, postoperative rebleeding, sepsis, prolonged ventilation, intensive care unit length of stay, and hospital length of stay were assessed using multivariable linear or logistic regression. Results: Five hundred fifty-nine patients who were evaluated through telehealth and 554 patients who were evaluated in person were included. The telehealth group had fewer women, smokers, dialysis-dependent patients, and patients on Medicare/Medicaid (all P values < .05); they underwent more isolated mitral (27% vs 20%; P = .006), and fewer isolated aortic procedures (3% vs 5%; P = .005). Adjusted 1-year mortality was similar between both groups (adjusted hazard ratio, .8; 95% CI, 04-1.4; P = .371). There was no difference in secondary outcomes between the 2 groups (all P values > .05). We found no difference in the proportion of patients with high Social Vulnerability Index between groups (12% vs 14%; P = .28). More telehealth patients resided further than 67 miles from the hospital (23% vs 17%; P = .03) and had median savings of 2.4 gas-gallons (range, 1.0-4.6 gas-gallons and 91.8 minutes (range, 39.6-182 minutes) of travel time. Conclusions: Our findings suggest that telehealth may be efficiently and safely used for preoperative evaluation of patients undergoing elective cardiac surgery.

BACKGROUND:In 2018, the US heart allocation policy was changed from 3 tiers to 6 tiers for a more granular assessment of patients' medical urgency. Given previous studies showing significant discrepancies in posttransplantation outcomes among Black and Hispanic minority groups, we investigated the effects of the allocation policy change on these groups. STUDY DESIGN:Adult heart transplantation patients from October 18, 2014, to October 18, 2022, were included from the United Network for Organ Sharing database. Multiorgan transplants and retransplants were excluded. One to one propensity matching was performed by race and ethnicity and allocation score era. The primary outcome was overall (4-year) survival assessed using multivariable Cox regression in an unmatched cohort; secondary outcomes were in-hospital and 1-year rejection, short-term mortality, and graft failure, assessed using conditional logistic regression in the matched cohort. RESULTS:The total cohort included 19,731 patients; 13,001 White, 4,784 Black, and 1,946 Hispanic. White, Black, and Hispanic cohorts in matched analysis demonstrated postallocation change improvements in in-hospital and 1-year rejection (all p < 0.05) and comparable short-term mortality and graft failure (all p > 0.05). In adjusted analyses, Black recipients had comparable overall mortality to White recipients both pre- (adjusted hazard ratio [aHR] 1.04 [0.92, 1.18], p = 0.514) and postallocation change (aHR 1.10 [0.95, 1.27], p = 0.194). Postallocation change, Black recipients had a higher risk of overall mortality (aHR 1.20 [1.01, 1.42], p = 0.033), whereas Hispanic recipients had lower risk of mortality (aHR 0.72 [0.55, 0.94], p = 0.015) compared with White recipients. CONCLUSIONS:This analysis demonstrates improved acute rejection rates postallocation change, by race and ethnicity; however, there remain disparities in short- and long-term recipient mortality for Black recipients in the postallocation change era. Future studies will explore the factors impacting long-term survival among these groups.