Advanced Echocardiographic Phenotyping of Myocardial Recovery During VA‐ECMO—A Scoping Review

Background Venoarterial extracorporeal membrane oxygenation (VA‐ECMO) provided temporary circulatory support in refractory cardiogenic shock but substantially altered ventricular preload, afterload, and native ejection. Consequently, conventional echocardiographic measurements obtained during support did not necessarily represent intrinsic myocardial contractility. This scoping review mapped conventional and advanced echocardiographic approaches used to characterize myocardial recovery and guide VA‐ECMO liberation. Methods PubMed, OpenAlex, and Crossref were searched from inception through September 20, 2026. Eligible studies included adults receiving VA‐ECMO in whom echocardiography was used to assess myocardial recovery, flow‐dependent cardiac performance, weaning readiness, decannulation outcomes, or transition to durable mechanical support. Citation searching supplemented the database searches. Study selection was reported according to PRISMA‐ScR, and the search process was documented according to PRISMA‐S. Data were synthesized descriptively because of substantial heterogeneity in populations, imaging protocols, flow‐reduction strategies, and outcome definitions. Results The searches identified 3,912 records, of which 2,834 remained after duplicate removal. Thirty‐nine full‐text reports were assessed, and 35 studies were included. Conventional measures, particularly left ventricular ejection fraction and left ventricular outflow tract velocity–time integral, were frequently associated with successful weaning but were strongly influenced by ECMO‐related loading conditions. Flow reduction commonly improved ejection fraction, longitudinal strain, native stroke output, and annular velocities without representing immediate biological myocardial recovery. Advanced phenotyping incorporated left ventricular global longitudinal strain, mitral annular plane systolic excursion, cardiac time intervals, left atrial reservoir strain, right ventricular free‐wall strain, three‐dimensional right ventricular ejection fraction, and right ventricular–pulmonary arterial coupling. Serial and flow‐challenge assessments provided greater prognostic information than isolated measurements under full support. Distinct trajectories included coordinated biventricular recovery, isolated left ventricular recovery, persistent biventricular failure, and refractory systolic stagnation. Successful decannulation did not consistently predict sustained recovery or survival, and integrated models combining echocardiography with pulsatility, filling pressures, vasoactive requirements, and end‐organ recovery showed the greatest clinical utility. Conclusions Echocardiographic assessment of myocardial recovery during VA‐ECMO had evolved from static ventricular thresholds toward dynamic, multiparametric phenotyping. No single parameter reliably established decannulation readiness. Standardized serial imaging and controlled flow‐reduction protocols that integrated biventricular function, deformation, native forward flow, ventricular–vascular coupling, filling pressures, and clinical stability were required. Prospective multicenter validation and harmonized definitions of sustained myocardial recovery remained necessary.