Four randomized trials published between 2020 and 2023 compared extracorporeal cardiopulmonary resuscitation (ECPR) to conventional cardiopulmonary resuscitation^1–4 and the controversial findings of the last one, the INCEPTION trial triggered great debates.^3,5 ECPR offers a rescue chance with a reasonable odd of favorable survival, while invasive protocols extend the window of potential successful resuscitation, providing an opportunity for effective intervention even beyond the conventional timeframe.^6,7 A new paradigm of resuscitation focused on neurological outcomes. Patients who received ECPR due to an out-of-hospital cardiac arrest (OHCA), compared with patients who received conventional CPR had a higher rate of survival with favorable neurological outcome 27% vs. 18%.⁸ When considering the subgroup with an initial shockable rhythm, ECPR increased the proportion of patients surviving with favorable neurological outcome up to 34% compared to conventional CPR (23%).⁸ Due to the meta-analysis of six large cohorts, ECPR compared to conventional CPR after cardiac arrest in any setting (in-hospital cardiac arrest (IHCA) and OHCA), was associated with improved long-term neurologically intact survival defined a priori as a Glasgow-Pittsburgh cerebral performance category (CPC) of 1 or 2.⁹ Of long-term survivors of the Prague OHCA trial, 1/34 (2.9%) in the ECPR-based arm and 1/26 (3.8%) in the conventional CPR arm had poor neurological outcome (CPC 3).¹⁰ Several data on long term neurological and functional outcomes in patients who received ECPR in out-of-hospital arrest are available.^10–17 ECPR accomplished a satisfactory neurological functioning and perceived quality of life quantified with the SF-36 questionnaire and CPC. Younger age and shorter length of hospitalization were associated with return to work, however ECPR compared to CPR was not.¹⁸ CPR duration remains a critical determinate of survival, and the likelihood of neurologically favorable survival declines with prolonged resuscitation.⁷ ECPR was associated with improved neurologically favorable survival at all CPR durations < 60 min despite severe progressive metabolic derangement.⁷