Extracorporeal membrane oxygenation (ECMO) has become an essential supportive therapy for patients with severe respiratory and/or cardiac failure. While conventional configurations such as veno-venous and veno-arterial ECMO have well-established roles, they are limited by important physiological trade-offs, particularly in patients with concomitant right ventricular dysfunction. Venopulmonary ECMO (VP ECMO) has emerged as a distinct and increasingly utilized configuration designed to provide right ventricular unloading while preserving physiologic pulmonary circulation and enabling extracorporeal gas exchange. By draining venous blood and returning it directly to the pulmonary artery, VP ECMO bypasses the failing right ventricle, reduces venous congestion, improves pulmonary hemodynamics, and supports gas exchange without the systemic complications associated with veno-arterial-ECMO. This review summarizes the physiological principles underlying VP ECMO, outlines cannulation strategies and configurations, and discusses clinical indications with an emphasis on patient phenotyping. Particular attention is given to its role in acute right ventricular failure, acute respiratory distress syndrome with right ventricular dysfunction, postleft ventricular assist device right heart failure, and as a bridge to lung transplantation. Emerging clinical evidence suggests that VP ECMO may improve hemodynamic stability, facilitate early mobilization, and enhance survival in carefully selected patients. However, data remain largely limited to observational studies and case series. Further prospective studies are required to refine patient selection, optimize timing, and define standardized management strategies for VP ECMO.