Although most extracorporeal membrane oxygenation (ECMO) centers are experienced in the treatment of neonatal respiratory failure, institutional expertise and need dictate the availability of pediatric and adult ECMO for respiratory or cardiac support. Since 1989, participating ECMO centers have voluntarily registered all patients with the Neonatal, Pediatric, and Adult ECMO Registry of the Extracorporeal Life Support Organization (ELSO). Venoarterial ECMO is recommended for patients with cardiovascular instability or inadequate cardiac output during cardio respiratory failure. The effects of ECMO on cardiac physiology include a decrease in preload, a slight increase in afterload, and an elevation in left ventricular wall stress. Advantages include biventricular support, improvement of systemic oxygenation, and ease of placement. Disadvantages of venoarterial ECMO include the need for major arterial access, reduced pulmonary blood flow, and the potential for arterial emboli. Doctor Ko and associates from Taiwan report a large, single institution, retrospective review of 76 adult cardiopulmonary bypass patients who received ECMO for post-cardiac surgery cardiogenic shock including patients who could not wean from cardiopulmonary bypass in the operating room. Their 6-year experience reflects a learning curve as well as local circumstances of few potential heart transplant donors and limited ventricular assist device availability. Therefore, this experience reflects use of ECMO on “all comers” who remain in cardiogenic shock following cardiac surgery, despite intraaortic balloon pump and inotropic support. Even with such broad indications, their survival to discharge ∼30% is comparable to the ELSO registry and other major reports. The authors emphasize several important aspects of their management including no circuit bridge, no systemic heparin for the first 24 hours and less frequent lab values. They also confirm patients with active bleeding, extensive pre-ECMO shock or acute renal failure will have poorer outcomes. The authors recommend excluding patients with uncontrolled bleeding and early implementation of ECMO when cardiogenic shock is unresponsive to intraaortic balloon pump and inotropes, to limit multiorgan dysfunction. The future of ECMO depends on techniques and devices to make the technique less invasive, safer, and simpler in management. Using percutaneous catheters without surgical insertion can reduce potential bleeding. Heparin-bonded oxygenators, pump chambers, and extracorporeal circuits may allow ECMO for several days without bleeding complications, or formation of clots. As demonstrated by Dr Ko and associates, expanded applications of ECMO include post-cardiac surgery cardiogenic shock. Based on this experience and others, ECMO can also be considered for other causes of acute cardiac failure.