The use of extracorporeal cardiopulmonary resuscitation (ECPR) has risen exponentially worldwide. Following favorable observational studies, randomized controlled trials yielded conflicting results in patients with out of hospital cardiac arrest when compared to conventional advanced life support. Additionally, several important questions remain incompletely answered, from patient selection criteria, logistics of care and post-cardiac arrest management, to cost-benefit thresholds, withdrawal of care and organ donation. We offer a narrative review of current literature, critically appraising the existing evidence and discussing pragmatic hurdles to ECPR implementation.