Targeted Nitroglycerin Infusion during VA-ECMO to Reduce LV Afterload and Prevent Pulmonary Edema: A Two-case Experience

Background/IntroductionVA-ECMO increases systemic afterload, leading to left ventricular (LV) distension, impaired aortic valve opening, and pulmonary edema.Controlled vasodilation with nitroglycerin (NTG), along with mechanical unloading such as intra-aortic balloon pump (IABP), may mitigate these effects.We present two acute myocardial infarction (AMI) patients on VA-ECMO in whom NTG infusion and IABP were used synergistically for LV unloading. MethodsTwo AMI patients with cardiogenic shock were supported with peripheral VA-ECMO.Both developed elevated after load, poor pulsatility, and limited aortic valve opening.IABP was inserted early in both cases as primary LV unloading.Low-dose NTG (0.25-0.5 g/kg/min) was subsequently titrated to maintain MAP 65-75 mm Hg.Serial echocardiography guided LV distension, AV opening, and pulmonary edema assessment. Results Case1 1 2 3 4 1 2,3 4 2/4/26, 1:17 PM ABSTRACTS ECMO -IJECMO2026 file:///C:/Users/Prabhat Shukla.DESKTOP-6HO8CNO/Downloads/Page Proof/IJECMO-4(S1)-html/IJECMO-4(S1)-html/IJECMO-4(S1)/4/S(1)/10.5 1/2 AMI with severe LV dysfunction, supported on VA-ECMO for 100 hours.IABP improved LV venting; NTG further enhanced AV opening, reduced LV distension, and enabled successful ECMO weaning.Patient discharged.Case 2 AMI with low EF requiring PCI to the left main artery.IABP was inserted at initiation, improving LV unloading.NTG infusion improved pulsatility, reduced pulmonary edema, and supported successful ECMO liberation after 7 days.Both patients were discharged.No NTG-related major hypotension occurred. LimitationsSmall sample size and observational format. ConclusionsCombined IABP and controlled NTG infusion during VA-ECMO were feasible and effective in improving LV unloading and hemodynamic stability.This strategy may be valuable where advanced unloading devices are limited, provided monitoring is meticulous.