Primary graft dysfunction presenting as severe right heartfailure（RHF）after heart transplantation may result inprofoundhemodynamic instability and often requires mechanical circulatory support. Extracorporeal membrane oxygenationisindicated for post-transplant right heart failure refractorytoconservative management, as it stabilizes circulationandbuystime for myocardial recovery or further intervention. Whilevenous-arterial extracorporeal membrane oxygenation(VA-ECMO) is conventionally employed, it can exacerbateleftventricular afterload. Venous-pulmonary artery ECMO(VPA-ECMO) represents a novel, afterload-sparing strategyforisolated RHF, though clinical evidence remains limited. However, in severe right heart failure, VPAECMOhasdemonstrated feasibility and the ability to stabilizehemodynamics. We share two successful cases fromourcenter in which VPA ECMO was used to manage right heartfailure after heart transplantation. In both patients, VPA-ECMOprovided effective hemodynamic stabilization withoutincreasing left ventricular afterload. No major device-related complications occurred. Both patients were successfullyweaned from ECMO. Detailed clinical pathways incorporatingmultimodal evaluation and stepwise weaning are presented. VPA-ECMO appears to be a feasible and effective optionforsevere RHF after heart transplantation. Our experienceprovides preliminary evidence supporting its clinical application, particularly in terms of patient selection, hemodynamic management, and weaning strategies. Furtherstudies are warranted to establish its role in this setting.

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