Patients with group 1 pulmonary arterial hypertension (PAH) and decompensated right heart failure (RHF) were not previously considered for extracorporeal membrane oxygenation (ECMO) as bridge to transplantation (BTT) or bridge to recovery (BTR) because options were limited by long transplantation wait times and perceived inability to wean ECMO. In a retrospective review, we describe our center’s multidisciplinary mechanical–medical approach to ECMO as a bridging therapy for PAH (2009–2012). Suitability for ECMO was determined using a defined algorithm. Six patients (age, 32 ± 11 years) underwent mechanical–medical bridging. Two transplant-eligible patients underwent successful BTT. The four patients ineligible for transplantation underwent BTR with escalation of targeted medical therapies before weaning off ECMO. Three of four BTR patients survived to ECMO decannulation (duration, 12 ± 7; range, 7–23 days). In this single-institution experience, mechanical–medical BTT and BTR with ECMO and targeted PAH therapies were used as a novel treatment strategy to successfully manage acute RHF in PAH.