*Purpose: Double Lung transplantation in the presence of extreme mediastinal shift can be technically challenging due to donor sizing and recipient factors.

*Methods: We present the case of a 53-year-old female with non-cystic fibrosis bronchiectasis, chronic respiratory failure on 4 liters home oxygen and severe secondary pulmonary hypertension with RV dysfunction. She was listed for bilateral lung transplantation at our center following evaluation.

*Results: While awaiting transplantation she went into acute right heart failure requiring invasive mechanical ventilation and veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) for hemodynamic support. Initial cannulation was peripherally placed into the right femoral artery and vein. She was subsequently transitioned to central VA ECMO cannulation via minimally invasive right anterior thoracotomy and right atrial and ascending aortic cannulation. She was maintained on VA ECMO for six days prior to receiving a suitable donor offer and undergoing bilateral sequential lung transplantation. Her imaging was notable for extreme rightward mediastinal shift due to the degree of right lung disease. Following transplantation, she was weaned off VA ECMO in the operating room and respiratory support over the following days. Her postoperative imaging showed resolution of mediastinal shift and marked improvement in right ventricular function.

*Conclusions: This case demonstrates that although appears daunting double lung transplantation can be undertaken safely even with extreme shift without need for graft reduction.

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