The early postoperative care of a heart transplant recipient remains challenging, even in experienced centers with a long tradition of excellence. Approximately 10% to 20% of heart transplant recipients experience potentially life-threatening right ventricular dysfunction intraoperatively and early postoperatively due to an elevated pulmonary vascular resistance. In addition, heart transplant recipients experience a high risk of perioperative hemorrhage, as well as opportunistic infection and rejection. The authors describe a case of severe right ventricular dysfunction in a 46-year-old male several hours after heart transplantation for a dilated cardiomyopathy. This patient was salvaged by judicious multimodality therapy including the use of adrenergic agents, phosphodiesterase inhibitors, inhaled nitric oxide, and extracorporeal membrane oxygenation. The risk factors for the development of early graft failure after heart transplantation are reviewed, along with the principles of appropriate management of this complication.