• Extracorporeal circuit hardware and blood-compatibility matured through iterative advances in oxygenators, heat exchangers, and tubing, coupled with early coagulation and hematology studies to reduce hemolysis and thrombotic risk [4], [7], [19], [20], [5], [17], [13], [11].

• Arterial counterpulsation and venoarterial bypass emerged as core strategies to augment cardiac output and coronary perfusion during failure, enabling hemodynamic support even before full heart-lung replacement [10], [14], [3], [6], [1].

• Hypothermia and cardioplegia were adopted to protect myocardium and provide a motionless field, facilitating open-heart procedures within extracorporeal circuits [9], [15], [16], [18].

• Hematologic management and coagulation considerations became a central concern, addressing abnormal bleeding, platelet function, and plasma-expander strategies during extracorporeal circulation [8], [20], [7], [17], [5].

• Clinical translation and integration of ECMO-relevant technology with anesthesia and cardiothoracic surgery practice reflected a systemic shift, from experimental devices to standardized operative protocols [2], [13], [16], [10], [19].