*Purpose: Retrospective analysis of UNOS data was performed to determine regional variation in the utilization and impact of VAD prior to HT in the United States.

*Methods: UNOS data for HT from 1/1/1988 – 3/30/2018 was analyzed to identify risk factors associated with graft survival both overall and by UNOS region. Statistical analysis included multivariate analysis, Kaplan-Meier and Cox regression methods.

*Results: The total number of HTs increased yearly and included 38,568 of which 20% were patients with VADs; overall pre-HT VAD increased proportionately and significantly over time. During 2010-2018 utilization of VAD varied significantly by geography; from 22% in region 3 to 90% in region 6. Overall survival was significantly better for those transplanted without vs. with prior VAD; yet graft survival for those with VAD increased by 37% during this time frame.

*Conclusions: As the adverse association of pre-HT VAD on post-transplant survival diminished over time, utilization of VAD became significantly more frequent. During the most recent 8 years, pre-HT patient management varied significantly by UNOS region. Region 6 practices and outcomes varied significantly from all other regions with the highest rates of VAD use and post-HT survival. As heart allocation increasingly incorporates broader sharing, the pre-HT utilization of VAD will continue to be important to consider.

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