This scoping review maps the evidence on ECMO anticoagulation strategies beyond unfractionated heparin. Across 135 included records, direct thrombin inhibitors—especially bivalirudin—were the most studied alternatives, while nafamostat, prostaglandin E1, circuit modifications, anticoagulation-free protocols, and newer monitoring tools remain emerging areas. The authors conclude that ECMO anticoagulation is shifting toward more personalized, diversified management.