Venopulmonary ECMO (VP ECMO) is an advanced support strategy for patients with severe respiratory failure and right ventricular (RV) dysfunction, providing pulmonary protection by oxygenating blood and unloading the RV. This case discusses a 57-year-old female with septic cardiomyopathy, refractory cardiogenic shock, and ARDS, who developed progressive respiratory deterioration despite conventional treatment. Due to patient instability, she was placed on VP ECMO (femoral venous drainage and pulmonary artery reinfusion), guided exclusively by transesophageal echocardiography (TEE). The use of TEE enabled successful pulmonary artery cannulation without the need for fluoroscopic guidance. Additionally, a flotation catheter was used to facilitate guidewire placement, improving procedural success in this emergent situation. After initiating ECMO, the patient showed significant clinical improvement, with resolution of RV dilation and paradoxical septal motion. This case underscores the feasibility and safety of TEE-guided VP ECMO, suggesting that the flotation catheter technique could be beneficial in critical situations, warranting further investigation to establish clinical guidelines.