The utility of mechanical support in pretransplant stabilization and postcardiotomy shock is well established, but its use in perioperative cardiac allograft failure (PCAGF) rescue has not been well documented. Ventricular assist devices (VADs) have been applied to PCAGF rescue with acceptable results. However, studies have not described the results of using extracorporeal membrane oxygenation (ECMO) in PCAGF. We evaluated the outcome of PCAGF rescue with ECMO. A retrospective review of 204 consecutive heart transplants revealed 19 cases of PCAGF requiring ECMO rescue. Donor-, surgery- and ECMO-related variables were evaluated for association with operative mortality, success of weaning, and survival rate. Transplant recipients included 14 males and 5 females with median age of 44.2 years. Weaning rate was 84.2% and survival rate was 52.6%, with duration of ECMO support 157 +/- 129 hours. Long ischemic time is a PCAGF risk factor (206.8 +/- 96.1 minutes vs. 158.3 +/- 60.8 minutes in non-PCAGF, p < 0.05). PCAGF etiology included primary graft failure (n = 7); right heart failure secondary to pulmonary hypertension, coagulopathy/intraoperative hemorrhage (n = 7); and sepsis (n = 2). Compared with data from VAD-supported PCAGF, ECMO had a better weaning and graft survival rates (p < 0.05). ECMO is another choice for PCAGF rescue. It has an acceptable survival rate and may be considered instead of VADs as a first-line rescue for PCAGF.