The surgical sequence of lung transplantation differs by extracorporeal support status. For patients not on ECMO, the procedure begins with dissection and pneumonectomy of the less functional lung, followed by sequential graft implantation with bronchial, pulmonary artery, and atrial anastomoses, bronchoscopy, gradual reperfusion, and differential ventilation. The contralateral lung is then transplanted similarly. In patients on ECMO, a clamshell incision is followed by systemic heparinization, central cannulation, and initiation of extracorporeal life support. Lungs are implanted sequentially while on ECMO with careful reperfusion and ventilation. Decannulation follows, with protamine reversal as needed.