With a few more questions, emerged that patient did not suffer any past medical problem, did not have any fever, headache or illness in the last 24 hours before cardiac arrest.
Historically, from the first extracorporeal successful cardiopulmonary support in 1953, when Professor Gibbon indication to extracorporeal life support was to sustain open heart surgery, today with miniaturisation of devices, improvement of technology, ECLS could be started successfully even in “Spoke” hospitals with percutaneous techniques with proper training and dedicated equipe. Guidelines have been written, but at the time inclusion criteria are not totally uniform. Extracorporeal Life Support Organisation, in December 2013, published guidelines for ECPR cases, writing that AHA guidelines for CPR recommends consideration of ECMO to aid cardiopulmonary resuscitation in patients who have an easily reversible event and have had excellent CPR. Instead, all contraindications to ECMO use (such as Gestational age < 34 weeks) should apply to ECPR patients. ELSO considered such a futility the cases in which unsuccessful CPR (no return of spontaneous circulation) for 5-30 minutes is performed, without considering the “time of no flow” before resuscitation providers arrival; however ECPR may be indicated on prolonged CPR if good perfusion and metabolic support is documented. .
Lazzeri et al. in their paperwork included all patients with an estimated interval of less than 15 minutes from the time of collapse to CPR start with or without witnessed CA, independently of rhythm of presentation. 
This case demonstrates how patients who present a shockable rhythm at the first contact (BLS or ALS team, independently), despite an not-witnessed “no flow time”, and who have recurrent cardiac arrest after the first ROSC, shall be always addressed to the nearest ECMO center, if logistically suitable. This observation is even more appropriate considering patients under 40 years without comorbidities. In fact there was a statistically significant reduction in the probability of survival to hospital discharge with increasing numbers of chronic conditions, such as congestive heart failure, prior myocardial infarction, hypertension, and diabetes (OR 0.84 for each additional chronic condition). The impact of comorbidities was more prominent with longer EMS response intervals. Furthermore inherited electrophysiological abnormalities, termed primary electrical diseases, are increasingly common in patients under 40 years without comorbidities .These conditions including Wolff-Parkinson White syndrome, long QT syndrome, Brugada syndrome and catecholaminergic polymorphic ventricular tachycardia (CPVT) are associated with a better outcome also after a prolonged CPR. (11)(12)
Interestingly, this patient had a probability of survival, at one month, of 68%, if considering only the initial rhythm (VF), but the dynamic probability to survive with a good cerebral function after 30 minutes of CPR is below 0,4% as demonstrated by Yoshikazu in a recent paperwork. In the same paper the authors demonstrated no survivors at 53 minutes of CPR. (13)
In this contest, it is especially important to have a defined ECMO center protocol: firstly in order to permit the support of the circulation and tissue perfusion if there is not any ROSC in the hospital, while appropriate treatment are being performed; secondly ECMO could assist the left ventricular function in case of a cardiogenic shock after ROSC.
Today, no clinical studies on ECPR are in literature and published series available have used strict criteria of inclusion and exclusion for patient selection for ECPR .
Although these inclusion criteria are highly variable, most of them only included patients aged between 18 and 75 years with comorbidity limited in circulatory arrest from cardiac origin, after traditional CPR for more than 10 minutes without ROSC. These inclusion criteria must be taken into account in the selection by the operator of potential candidates to ECPR. 
ECPR, as mentioned in the latest AHA guidelines on CPR and ECC, can be considered an alternative to the traditional CPR for cardiac arrest in selected patients and for which the suspected etiology of cardiac arrest is potentially reversible. 
- Guidelines ACLS , American Heart Association 2016
- Gräsner J-T, et al. A prospective one month analysis of out-of-hospital cardiac arrest outcomes in 27 countries in Europe. Resuscitation 68121-7 (2016).
- Lee et al., Out-of-hospital cardiac arrest patients treated with cardiopulmonary resuscitation using extracorporeal membrane oxygenation: focus on survival rate and neurologic outcome Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2016) 24:74.
- Reynolds J. C. et al., Duration of resuscitation efforts and functional outcome after out-of-hospital cardiac arrest: when should we change to novel therapies? 2013;128(23):2488–2494.
- Ornato J.P. et al., The Public Access Defibrillation (PAD) trial: study design and rationale. Resuscitation. 2003;56(2):135–147. doi: 10.1016/S0300-9572(02)00442-2. Shih C.-L., Lu T.-C., Jerng J.-S., et al. A web-based Utstein style registry system of in-hospital cardiopulmonary resuscitation in Taiwan. Resuscitation. 2007;72(3):394–403. doi: 10.1016/j.resuscitation.2006.07.020.
- Kim et al., An optimal transition time to extracorporeal cardiopulmonary resuscitation for predicting good neurological outcome in patients with out-of-hospital cardiac arrest: a propensity-matched study. Critical Care 2014, 18:535
- ELSO ECPR Supplement to the ELSO general guidelines, December 2013, version 1.3 Pag.
- Lazzeri C. et al., Extracorporeal life support for out-of-hospital cardiac arrest: Part of a treatment bundle. European Heart Journal, Acute Cardiovascular Care, 2015 May 12.
- American Heart Association, Guidelines 2015 on CPR and ECC.
- Poppe M. et al., The incidence of “load&go” out-of-hospital cardiac arrest candidates for emergency department utilisation of emergency extracorporeal life support: A one-year review. Resuscitation 91 (2015) 131–136
- RescueNet Software, at: http://www.zoll.com/medical-products/data-management/rescue-net-fire-ems/code-review
- Carew Ht et al., Chronic health conditions and survival after out-of-hospital ventricular fibrillation cardiac arrest. Heart 2007; 93:728
- Yoshikazu Goto et al. Relationship between the duration of cardiopulmonary resuscitation and favorable neurological outcomes after out of hospital cardiac arrest; A prospective, nationwide, population based color study. J Am Heart Assoc. 2016;5:e002819 doi: 10.1161/JAHA. 115002819