Extracorporeal cardiopulmonary resuscitation is a promising treatment for refractory out-of-hospital cardiac arrest. Three recent randomized trials (ARREST trial, Prague OHCA study, and INCEPTION trial) that addressed the clinical benefit of extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest yielded seemingly diverging results. The evidence for extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest, derived from three recent randomized controlled trials, is not contradictory but rather complementary. Excellent results can be achieved with a very high level of dedication, provided that strict selection criteria are applied. However, pragmatic implementation of extracorporeal cardiopulmonary resuscitation does not necessarily lead to improved outcome of refractory out-of-hospital cardiac arrest. Centres that are performing extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest or aspire to do so should critically evaluate whether they are able to meet the pre-requisites that are needed to conduct an effective extracorporeal cardiopulmonary resuscitation programme.

2nd Department of Medicine Department of Cardiovascular Medicine 1st Medical School General University Hospital and Charles University Prague U Nemocnice 2 Prague Czech Republic

Cardiovascular Research Institute Maastricht Maastricht University Maastricht The Netherlands

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

Department of Anesthesia and Pain Medicine Maastricht University Medical Center Maastricht The Netherlands

Department of Cardiology Maastricht University Medical Center Maastricht The Netherlands

Department of Cardiothoracic Surgery Maastricht University Medical Center Maastricht The Netherlands

Department of Intensive Care Medicine Maastricht University Medical Center Maastricht The Netherlands

School of Nutrition and Translational Research in Metabolism Maastricht University Maastricht The Netherlands

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