Abstract Background Adult liver transplantation (OLT) recipients occasionally show serious acute cardiopulmonary dysfunction, requiring intensive care. We assessed the role of extracorporeal membrane oxygenation (ECMO) support in adult recipients facing acute pulmonary failure and refractory to conventional mechanical ventilation and concurrent nitric oxide gas inhalation. Methods From January 2008 to March 2011, 18 adult OLT recipients at our institution required ECMO support: 12 due to pneumonia and 6 to adult respiratory distress syndrome. Their mean age was 55.7 ± 6.9 years and mean Model for End-stage Liver Disease score, 24.8 ± 8.5. Twelve patients had undergone living donor and six deceased donor OLT. Results A venovenous access mode and concurrent continuous venovenous hemodiafiltration were used in all patients. There were no procedure-related complications. Eight patients (44.4%) were successfully weaned from ECMO upon the first attempt after a mean support of 11.9 ± 6.1 days, but the other 10 died due to overwhelming infection. Univariate analysis revealed no significant pre-ECMO risk factor for treatment failure but C-reactive protein concentration at the time of ECMO differed significantly among patients who did versus did not survive after ECMO. Conclusions ECMO as rescue therapy may be a final therapeutic option for OLT recipients with refractory pulmonary dysfunction who would otherwise die due to hypoxemia from severe pneumonia or adult respiratory distress syndrome.