The survival rate of 62% of our patients treated with ECMO for respiratory failure is comparable to other published studies. In 2004, Hemmila and co-workers retrospectively reviewed 255 patients with ARDS treated with ECMO between 1989 and 2004, showing a 67% of patients successfully weaned from ECMO and a hospital discharge of 52% [20] . More recently, the CESAR (Conventional ventilation or ECMO for Severe Adult Respiratory Failure) trial has shown an increase of survival rate, without severe disability, 6 months after randomization in patients treated with ECMO in comparison to conventional ventilation (63% vs 47%) [4] . From the first phase of implementation, our service was conceived to provide extracorporeal support even in peripheral institutions, therefore a dedicated ambulance was specifically prepared and all equipment arranged for transportation. In our opinion, this is a key feature for an effective ECMO service as inter-hospital transportation of patients with severe respiratory failure can be challenging due to the fact that limited possibilities of intervention are available and clinical deterioration may occur [21] . Therefore, several centres recommend the start of extracorporeal assistance before transfer [22, 12] . In our out-of-hospital ECMO experience, one patient was safety transferred by ambulance from a distance of 400 Km. We report quite a short time to establish V-A ECLS in case of in-hospital cardiac arrest (58 min). Furthermore, there is a trend towards a progressive reduction of this interval over time. Despite this remarkable performance of our ECLS system in terms of speed of response, no patient receiving extracorporeal support for cardiac arrest survived. In a large series of patients on extracorporeal support for in hospital cardiac arrest, Jaski and coworkers reported a long term survival rate of 23% in witnessed events and no survival in non-witnessed arrest. At multivariate analysis cardiac arrest in the critical care unit was found to be the only independent variable predictive of outcome [23] . In another series of 40 in-hospital cardiac arrest victims, time before ECLS was 105 minutes, and 20% survival rate was reported [24] . In our experience, the number of cardiac arrest patients with ECLS is so limited that comparison to published data is not feasible. Nevertheless, the reason for not responding to V-A ECLS treatment in our cases might be possibly related to the severity of previous clinical condition (2 traumas, 1 septic shock) and to the underling organ dysfunction.