SINCE THE FIRST lung transplant in 1963¹ and the introduction of extracorporeal membrane oxygenation (ECMO) as a bridge to transplant (BTT) in 1977,² both have advanced remarkably. Lung transplantation is now an established therapy, while ECMO has evolved from experimental use to becoming an integral component of care across all stages of transplant. Yet questions of optimal patient selection, timing, and long-term outcomes remain. For much of this period, care was guided largely by specialty-specific opinion rather than multidisciplinary evidence. The recent development of a consensus statement from the International Society for Heart and Lung Transplantation (ISHLT) drawing on broad expertise represents a step forward in standardizing care for this high-risk population.