Acute-on-chronic right ventricular failure has a tremendously high mortality rate and pulmonary artery hypertension plays a major role in the progression of secondary right ventricular failure. Here, we report a case of drug-refractory acute-on-chronic right ventricular failure due to primary artery hypertension and a two-step approach of a percutaneous dual-outflow extracorporeal membrane oxygenation support set-up implanted under on-going mechanical resuscitation for immediate biventricular support with a consequent downgrade to right ventricular assist device after left ventricular recompensation.