Extracorporeal membrane oxygenation (ECMO) has been available for decades, with its use steadily expanding in the setting of advances in technology. The most common indications for venovenous and venoarterial ECMO remain severe hypoxemic respiratory failure and cardiogenic shock, respectively. Refinements in extracorporeal circuitry and cannulation strategies have led to novel indications for ECMO in cardiopulmonary failure, including pulmonary hypertension, extracorporeal cardiopulmonary resuscitation, and less severe forms of the acute respiratory distress syndrome. There is hope for the development of destination device therapy, which could have significant implications for acute and chronic management of severe respiratory and cardiac disease.