Disparities while listing for orthotopic heart transplantation: A systematic review and meta-analysis.
Phutinart, S., et alTransplant Rev (Orlando). 2025 Dec;39(4):100968.
Aims
The aim of this study was to evaluate how demographic, socioeconomic, and policy-related factors contribute to disparities within the orthotopic heart transplant listing process.
Interventions
MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews were searched for relevant literature. The methodological quality was assessed using the Newcastle-Ottawa Scale for observational studies, the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool for non-randomised interventional studies and the Cochrane Risk of Bias 2 (RoB 2) tool for randomised controlled trials.
Participants
40 studies were included in the review.
Outcomes
Primary outcome: recipient acceptance rate Secondary outcome: donor acceptance rate, and waitlist urgency, mortality, and duration.
Follow-up
N/A
CET Conclusions
This systematic review and meta-analysis addresses an important issue in heart transplantation: the likelihood of waitlist acceptance and progression to transplantation. Methodologically, the review is well conducted and was prospectively registered on PROSPERO, with adherence to PRISMA and MOOSE guidance. The literature search was broad, including MEDLINE, EMBASE, and Cochrane databases. Dual, independent trial selection and data extraction was used, reducing selection and extraction bias. The included population of patients is very large, standing at over 500,000 individuals across 40 studies. The review process demonstrates several strengths: heterogeneity was formally assessed, and appropriate fixed or random-effects models were selected. The authors also explored temporal effects surrounding the 2018 UNOS allocation changes, although many studies were from outside the USA. Nevertheless, there are limitations that reduce certainty. All of the included studies were observational, predominantly registry-based, and therefore susceptible to residual confounding—particularly from unmeasured clinical severity, referral bias, and centre-level practices. Although minimum quality thresholds were imposed (Newcastle-Ottawa Score >7), such instruments incompletely capture structural and systemic biases relevant to race and socioeconomic status. The primary endpoint, “recipient acceptance,” is variably defined across studies and may reflect centre behaviour, patient preference, or incomplete documentation. High heterogeneity was present in several secondary outcomes. Despite these weaknesses, the finding of persistently lower acceptance rates for Black candidates on to heart transplant lists is consistent across analyses. The authors’ conclusion that race remains a dominant determinant of inequity at listing is supported by the evidence presented, although causal interpretation should be made with caution.
Trial registration
PROSPERO - CRD420251108587