Rates of survival with functional recovery for both in-hospital and out-of-hospital cardiac arrest are notably low. Extracorporeal cardiopulmonary resuscitation (ECPR) is emerging as a modality to improve prognosis by augmenting perfusion to vital end-organs by utilizing extracorporeal membrane oxygenation (ECMO) during conventional CPR and stabilizing the patient for interventions aimed at reversing the aetiology of the arrest. Implementing this emergent procedure requires a substantial investment in resources, and even the most successful ECPR programs may nonetheless burden healthcare systems, clinicians, patients, and their families with unsalvageable patients supported by extracorporeal devices. Non-randomized and observational studies have repeatedly shown an association between ECPR and improved survival, versus conventional CPR, for in-hospital cardiac arrest in select patient populations. Recently, randomized controlled trials suggest benefit for ECPR over standard resuscitation, as well as the feasibility of performing such trials, in out-of-hospital cardiac arrest within highly coordinated healthcare delivery systems. Application of these data to clinical practice should be done cautiously, with outcomes likely to vary by the setting and system within which ECPR is initiated. ECPR introduces important ethical challenges, including whether it should be considered an extension of CPR, at what point it becomes sustained organ replacement therapy, and how to approach patients unable to recover or be bridged to heart replacement therapy. The economic impact of ECPR varies by health system, and has the potential to outstrip resources if used indiscriminately. Ideally, studies should include economic evaluations to inform health care systems about the cost-benefits of this therapy.

2nd Department of Medicine 1st Faculty of Medicine Charles University and General University Hospital Prague Czech Republic

Adult Intensive Care Services Prince Charles Hospital Brisbane Australia

Adult Intensive Care Unit Royal Brompton Hospital London UK

Bond University Gold Coast Australia

Cardiothoracic Intensive Care Unit Department of Cardiac Thoracic and Vascular Surgery National University Health System Singapore Singapore

Cardiothoracic Surgery Department Heart and Vascular Centre Maastricht University Medical Centre Cardiovascular Research Institute Maastricht Maastricht The Netherlands

Center for Acute Respiratory Failure Columbia University Irving Medical Center New York NY USA

Center for Resuscitation Medicine University of Minnesota Medical School Minneapolis MN USA

Department of Intensive Care Hôpital Erasme Université Libre de Bruxelles Brussels Belgium

Department of Medicine Division of Cardiology Beth Israel Deaconess Medical Center Harvard Medical School Boston MA USA

Department of Perfusion University Hospital Gasthuisberg Leuven Belgium

Department of Surgery National Taiwan University Hospital Taipei Taiwan

Department of Thoracic and Cardiovascular Surgery Korea University Medicine Seoul Republic of Korea

Division of Cardiac Vascular and Thoracic Surgery Columbia University Medical Center New York USA

Division of Cardiology Department of Medicine NewYork Presbyterian Columbia University Irving Medical Center New York NY USA

Division of Cardiothoracic Surgery Department of Surgery University of Utah Health Salt Lake City UT USA

Division of Emergency Medicine Department of Surgery University of Utah Health Salt Lake City UT USA

Division of Pulmonary Allergy and Critical Care Medicine Department of Medicine Columbia University Vagelos College of Physicians and Surgeons 622 W168th St PH 8E Room 101 New York NY 10032 USA

Institute of Cardiometabolism and Nutrition Sorbonne Université Paris France

Intensive Care Unit APHP Hopital Européen Georges Pompidou Inserm U 970 Université de Paris Paris France

Interdepartmental Division of Critical Care Medicine Department of Medicine University of Toronto Toronto Canada

Keenan Research Center St Michael's Hospital Li Ka Shing Knowledge Institute Toronto Canada

National Heart and Lung Institute Imperial College London UK

Service de Médecine Intensive Réanimation Hôpitaux Universitaires Pitié Salpêtrière Assistance Publique Hôpitaux de Paris Institut de Cardiologie Paris France

University of Queensland Brisbane Australia

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