Tehran University of Medical Sciences Archives of Anesthesiology and Critical Care 2423-5849 0 0 2026 10 24 1641 1641 Alvionita Fitriana Study Program of Anesthesiology and Intensive Care, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia. Fajar Perdhana Study Program of Anesthesiology and Intensive Care, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia. & Department of Anesthesiology and Reanimation, Dr Soetomo General Academic Hospital,, Surabaya, Indonesia. 2026 05 23 2026 07 01 Lung reperfusion injury (LRI) is a rare but severe complication following pediatric cardiac surgery with cardiopulmonary bypass in patients with complex congenital heart disease. We report two cases of postoperative LRI with different clinical outcomes. The first patient, a 9-year-old female with tetralogy of Fallot, developed severe hypoxemic respiratory failure and ARDS on postoperative day 2 and recovered after timely veno-arterial extracorporeal membrane oxygenation (VA-ECMO). The second patient, a 14-month-old male with situs ambiguus, right isomerism, and double outlet right ventricle, progressed to ARDS and multiorgan failure despite maximal conventional therapy and died on postoperative day 10 without ECMO support. These cases emphasize the importance of early recognition of LRI and timely ECMO initiation in selected patients with refractory respiratory failure. https://aacc.tums.ac.ir/index.php/aacc/article/view/1641