Background <p>Extracorporeal cardiopulmonary resuscitation (ECPR) is a potential treatment for selected patients with refractory out-of-hospital cardiac arrest (OHCA). Randomized controlled trials (RCTs) emphasize the importance of appropriate patient selection. Expert consensus statements recommend six criteria for ECPR suitability: age ≤ 75 years, witnessed OHCA, bystander cardiopulmonary resuscitation (CPR), no-flow time ≤ 5 min (min), low-flow time ≤ 60 min, and an initial shockable rhythm. Although widely accepted, these items are not supported by robust data and adherence varies greatly. We present an analysis from the German Cardiac Arrest Registry (G-CAR) describing the current state of ECPR across participating centers.</p> Results <p>Of 1,644 patients in G-CAR, 576 patients (34.6%) were admitted with ongoing CPR. Of these, 162 (28.0%) were treated with ECPR. Only 18 patients (11.0%) met all six ECPR criteria, with the majority displaying five (37.0%) or four (25.9%) characteristics. Overall, rates of favorable neurological survival at 30 days did not differ between patients treated with ECPR and those treated conventionally (8.6% vs. 5.6%, <i>p</i> = 0.25). When stratified according to the number of criteria, the probability of survival was higher in patients meeting all six or five compared to those meeting one to four criteria (20.0% vs. 11.9% vs. 1.4%; <i>p</i> = 0.028). A similar gradient in survival according to the number of fulfilled criteria was observed in conventionally treated patients.</p> Conclusions <p>Adherence to proposed ECPR selection criteria was low in this real-world cohort, potentially contributing to lower survival rates compared with results from RCTs. However, when all criteria were fulfilled, survival rates were significantly higher, underscoring the importance of stringent patient selection.</p> Graphical Abstract <p>OHCA: out-of-hospital cardiac arrest; CPR: cardiopulmonary resuscitation; ECPR: extracorporeal cardiopulmonary resuscitation</p> <p></p>