The purpose of this study is to compare the technique of performing bilateral lung transplantation off-pump versus venoarterial ECMO; researchers aim to determine which technique has lower rates of lung dysfunction. Both techniques are accepted methods of doing lung transplantation around the world. Veno-atrial ECMO Bilateral Orthotopic Lung Transplantation (VA ECMO) involves a combination of veno-atrial ECMO (a type of life support that helps both the heart and lungs) and a bilateral orthotopic lung transplant, where both diseased lungs are replaced with a healthy donor lung. The ECMO machine takes over the work of the heart and lungs temporarily during the transplant procedure, which helps maintain blood flow and oxygen levels while the new lungs are being implanted. The Off-Pump Bilateral Orthotopic Lung Transplantation (BOLT) is a type of lung transplant in which both lungs are replaced. "Off-pump" means the surgery is done with the patient’s own heart and lungs. The patient's diseased lungs are removed and replaced with healthy donor lungs while the heart and lung continue to function; this approach aims to reduce the risk of complications associated with using an artificial circuit to replace the heart and lungs. All routine care procedures will take place in the hospital operating room or ICU. Participants will have regular continuous transplant follow-up care, which is routine, and clinical data will be collected for research purposes.