Extracorporeal cardiopulmonary resuscitation (ECPR) can achieve survival approaching 30% for selected patients with refractory out-of-hospital cardiac arrest, but success depends on the entire system of care. This contemporary review examines patient selection, EMS optimization, geographic planning, rapid transport, hospital-based, rendezvous and prehospital ECPR models, specialized cardiac arrest centers, postresuscitation care, cost effectiveness, and continuous quality improvement.