Debora Emanuela Torre, Carmelo Pirri
Background: Hemodynamic management in veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is inherently complex, as extracorporeal circulation profoundly alters preload, afterload, ventriculo-arterial coupling and tissue perfusion. This review summarizes current and emerging monitoring strategies to guide initiation, maintenance and weaning. Methods: A structured literature search was performed in PubMed and Scopus (1990–2025), including clinical studies, consensus statement and expert reviews addressing hemodynamic monitoring in V-A ECMO. Results: A multiparametric framework is required. Echocardiography remains central for assessing biventricular performance, aortic valve dynamics and ventricular unloading. Pulmonary artery catheterization provides complementary data on filling pressures, cardiac output and global oxygen balance. Metabolic indices such as lactate clearance and veno-arterial CO2 gap, together with regional oximetry (NIRS), inform the adequacy of systemic and tissue perfusion. Microcirculatory monitoring, though technically demanding, has shown prognostic value, particularly during weaning. Additional adjuncts include arterial pulse pressure, end-tidal CO2 and waveform analysis. Phenotype oriented priorities, such as detection of differential hypoxemia, prevention of left ventricular distension or surveillance for limb ischemia, require tailored monitoring strategies. Artificial intelligence and machine learning represent future avenues for integrating multiparametric data into predictive models. Conclusions: No single modality can capture the hemodynamic complexity of V-A ECMO. Precision monitoring demands a dynamic, phenotype-specific and time-dependent approach that integrates systemic, cardiac, metabolic and microcirculatory variables. Such individualized strategies hold promise to optimize outcomes, reduce complications and align V-A ECMO management with the principles of precision medicine.