The use of venovenous extracorporeal membrane oxygenation (V-V ECMO) in adult patients with acute severe but potentially reversible respiratory failure remains controversial and it is recommended that V-V ECMO is restricted to a small number of specialised centres. We present a case in which initiating V-V ECMO in a large teaching hospital, complemented with mechanical circulatory support using an Impella® device, was lifesaving in a 55-year-old man with severe respiratory failure secondary to massive gastric aspiration and cardiogenic shock following cardiac arrest. V-V ECMO may be lifesaving in some well-selected patients with life-threatening hypoxaemia, even if the hypoxaemia is of combined cardiac and pulmonary origin. For additional circulatory support, Impella® might be a better choice than veno-arterial ECMO, because of avoiding an increase in left atrial pressure. In a rapidly deteriorating patient it may be necessary to initiate V-V ECMO immediately, outside an ECMO centre of expertise. In such situations, it is of paramount importance to have a close collaboration with an ECMO centre of expertise. © 2020, Netherlands Society of Intensive Care. All rights reserved.