Data on proper timing of transplantation are limited, particularly for individual lesions. Larger studies based on transplant databases do not allow for analysis based on the type of CHD.S3.14.2-1 Currently, patients with ACHD may have fewer mechanical circulatory devices (eg, ventricular-assist devices), which may lower their listing status and hence potential for organ receipt.S3.14.2-1,S3.14.2-2,S3.14.2-4 S3.14.2-7 Although specific criteria for timing of referral for transplantation are desirable, universal recommendations cannot be made based on current data. Generally, pub- lished data show that immediate and early posttransplan- tation risk is higher in ACHD than in acquired heart di- sease because of increased perioperative mortality.S3.14.2-2 However, once beyond the perioperative period, patients with ACHD do as well as or better than those with ac- quired heart disease, with expected 10-year survival e- quivalent to or better than that of patients without Risks for poor outcomes include single ventricle anatomy, anatomic complexity, protein-losing enteropathy, or high titers of panel reac- The current allocation system puts patients with ACHD at a disadvantage. Rather than priority dictated by the usual accepted risk markers, pa- tients with ACHD are often listed by exception, a pro- cess that requires the clinician to argue that the patient warrants higher priority than would be evident by apply- ing the used risk markers. There is also significant mortal- ity for patients with ACHD while on the waitlist.S3.14.2-10, Surgical alternatives to transplantation exist for some patients with CHD (eg, valve replacement, shunt closure), but these patients are at high risk of periopera- Ideally, providers will consider early referral to a transplant center with expertise in ACHD transplantation when transplantation becomes a relevant clinical consideration. Additionally, it is advisable to con- sider options for transplantation or ventricular assist de- vice as a backup before other high-risk surgery is pursued. 