Reperfusion is often the most challenging aspect of solid organ transplant, as the anesthesiologist must simultaneously manage the accompanying hemodynamic, ventilatory, and metabolic derangements. Whether on or off ECMO, reperfusion requires precise coordination between surgical and anesthetic teams. Reperfusion begins with controlled pulmonary artery unclamping to minimize the risk of reperfusion injury. Recruitment maneuvers and lung-protective ventilation at low FiO2 optimize graft compliance and minimize injury. Ventilation strategies are tailored per graft performance, with iNO used as needed. On ECMO, gas exchange is supported, allowing gentler reperfusion and gradual weaning. Associated risks include hypotension, hypoxia, coronary air embolism, and early graft dysfunction. Close monitoring, frequent ABGs, and readiness to escalate to ECMO are essential for safe reperfusion and graft function.