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Encouraging results of extracorporeal cardiopulmonary resuscitation for patients with refractory cardiac arrest have been shown. However, the independent impact on the neurologic outcome remains unknown in the out-of-hospital population. Our objective was to compare the neurologic outcome following extracorporeal cardiopulmonary resuscitation and conventional cardiopulmonary resuscitation and determine potential predictors that can identify candidates for extracorporeal cardiopulmonary resuscitation among patients with out-of-hospital cardiac arrest of cardiac origin.Post hoc analysis of data from a prospective observational cohort.A tertiary care university hospital in Sapporo, Japan (January 2000 to September 2004).A total of 162 adult patients with witnessed cardiac arrest of cardiac origin who had undergone cardiopulmonary resuscitation for longer than 20 minutes (53 in the extracorporeal cardiopulmonary resuscitation group and 109 in the conventional cardiopulmonary resuscitation group).None.The primary endpoint was neurologically intact survival at three months after cardiac arrest. We used propensity score matching to reduce selection bias and balance the baseline characteristics and clinical variables that could potentially affect outcome. This matching process selected 24 patients from each group. The impact of extracorporeal cardiopulmonary resuscitation was estimated in matched patients. Intact survival rate was higher in the matched extracorporeal cardiopulmonary resuscitation group than in the matched conventional cardiopulmonary resuscitation group (29.2% [7/24] vs. 8.3% [2/24], log-rank p = 0.018). According to the predictor analysis, only pupil diameter on hospital arrival was associated with neurologic outcome (adjusted hazard ratio, 1.39 per 1-mm increase; 95% confidence interval, 1.09–1.78; p = 0.008).Extracorporeal cardiopulmonary resuscitation can improve neurologic outcome after out-of-hospital cardiac arrest of cardiac origin; furthermore, pupil diameter on hospital arrival may be a key predictor to identify extracorporeal cardiopulmonary resuscitation candidates.