© 2018 American College of Cardiology Foundation Objectives: The purpose of this study was to compare trends of use, in-hospital mortality, and annual expenditures associated with orthotopic heart transplantation (OHT) and left ventricular assist device (LVAD) implantation. In view of the changing health care landscape, we assessed the impact of federal funding cuts on Medicare and Medicaid beneficiaries seeking these procedures. Background: Use and cost trends associated with OHT and LVAD are not well defined. Moreover, little is known about the economic contribution of Medicare and Medicaid for these procedures. Methods: Using the National Inpatient Sample from 2009 through 2014, the study identified index hospitalizations for OHT and LVAD. The aforementioned trends and inflation-adjusted cost analyses were performed. Results: A total of 28,765 hospitalizations associated with OHT or LVAD were identified. The number of index hospitalizations for OHT increased from 1,795 to 2,140, whereas the number of LVAD implants increased from 2,205 to 3,645 (ptrend <0.001 for both). Unadjusted in-hospital mortality declined significantly from 17% to 12% (ptrend = 0.013) but remained unchanged for OHT (4.5% and 6.6%, respectively; ptrend = 0.30). The annual expenditure increased from ∼$288 to $451 million for OHT and from ∼$400 to $800 million for LVAD during the study period. Overall, Medicare and Medicaid contributed to more than 50% of the costs associated with these hospitalizations. Conclusions: With increasing use and annual expenditure, OHT and LVAD account for more than 1 billion dollars of the health care budget. In-hospital mortality associated with LVAD has continued to decline but has remained higher than that with OHT. Medicare and Medicaid beneficiaries seeking these procedures would be adversely affected by the proposed cuts.