Purpose: Veno‑arterial (VA) extracorporeal membrane oxygenation (ECMO) can be used to restore organ perfusionin patients with cardiogenic shock until native heart recovery occurs. It may be challenging, however, to determinewhen patients can be weaned successfully from ECMO—surviving without requiring further mechanical supportor heart transplant. We aimed to systematically review the medical literature to determine the biomarkers, hemody‑namic and echocardiographic parameters associated with successful weaning of VA‑ECMO in adults with cardiogenicshock and to present an evidence‑based weaning algorithm incorporating key findings.

Method: We systematically searched PubMed, Embase, ProQuest, Google Scholars, Web of Science and the Greyliterature for pertinent original research reports. We excluded studies limited to extracorporeal cardiopulmonaryresuscitation (ECPR) as the neurological prognosis may significantly alter the decision‑making process surroundingthe device removal in this patient population. Studies with a mixed population of VA‑ECMO for cardiogenic shockor cardiac arrest were included. We excluded studies limited to patients in which ECMO was only used as a bridgeto VAD or heart transplant, as such patients are, by definition, never “successfully weaned.” We used the Risk of BiasAssessment tool for Non‑Randomized Studies. The study was registered on the International prospective register ofsystematic reviews (PROSPERO CRD42020178641).

Results: We screened 14,578 records and included 47 that met our pre‑specified criteria. Signs of lower initial severityof shock and myocardial injury, early recovery of systemic perfusion, left and right ventricular recovery, hemodynamicand echocardiographic stability during flow reduction trial and/or pump‑controlled retrograde trial off predictedsuccessful weaning. The most widely used parameter was the left ventricular outflow tract velocity time integral, anindicator of stroke volume. Most studies had a moderate or high risk of bias. Heterogeneity in methods, timing, andconditions of measurements precluded any meta‑analysis.

Conclusions: In adult patients on VA‑ECMO for cardiogenic shock, multiple biomarkers, hemodynamic and echocar‑diographic parameters may be used to track resolution of systemic hypoperfusion and myocardial recovery in orderto identify patients that can be successfully weaned.