Prolonged Heparin-free VV ECMO Supported With Nitric Oxide in Severe ARDS With Airway Hemorrhage — A Case Report

Systemic anticoagulation is routinely used during VV ECMO to prevent thrombotic complications.However, major bleeding may necessitate anticoagulation withdrawal, leaving limited evidence-based management strategies.Adjunctive inhaled nitric oxide (iNO) has been proposed to improve hemocompatibility by reducing platelet activation and microvascular thrombosis.We report successful prolonged VV ECMO without anticoagulation, supported by iNO, in a patient with life-threatening airway hemorrhage. MethodsA 32-year-old woman with severe ARDS secondary to viral pneumonia (PF ratio 45) was initiated on VV ECMO after failing lung-protective ventilation and proning.Following bronchoscopy-guided percutaneous tracheostomy, mucosal bleeding developed with APTT >180 seconds, prompting discontinuation of heparin.ECMO flows were maintained >4 L/min using a biocompatible Maquet PLS circuit.iNO was initiated to reduce thrombogenic risk and continued for 10 days.Serial laboratory monitoring, bronchoscopy, ventilator optimization, and daily circuit thrombosis surveillance were performed. ResultsThe patient remained on ECMO for 546 hours (22 days 18 hours), including 10 days heparin-free with iNO.No circuit thrombosis, oxygenator dysfunction, or thromboembolic events occurred, and no circuit exchange was required.APTT 1 2 3 1 2 3 2/4/26, 1:15 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 1/2normalized gradually, bleeding settled, respiratory function improved, and ECMO was successfully weaned and decannulated on Day 23.The patient was discharged neurologically intact and clinically stable. LimitationsSingle-center experience, observational nature, and inability to determine causality between iNO use and thrombosis prevention.Results may not be generalizable. ConclusionsProlonged heparin-free VV ECMO may be feasible in selected bleeding-risk patients when supported by stable flows, vigilant circuit surveillance, and iNO.Nitric oxide may offer adjunct hemocompatibility benefit, warranting further systematic evaluation.