Extracorporeal membrane oxygenation (ECMO) is described as a modified, smaller cardiopulmonary bypass circuit. The veno-venous (VV) ECMO circuit drains venous blood, oxygenate the blood, and pump the blood back into the same venous compartment. Draining and reinfusing in the same compartment means there are a risk of recirculation. The draining position within the venous system, ECMO pump flow, return flow position within the venous system and the patients cardiac output (CO) all have an impact on recirculation. Using two single lumen cannulas or one dual lumen cannula, but also the design of the venous cannula, can have an impact on where within the venous system the cannula is draining blood and will affect the efficiency of the ECMO circuit. VV ECMO can be performed with different cannulation strategies. The use of two single lumen cannulas draining in inferior vena cava (IVC) and reinfusing in superior vena cava (SVC) or draining in SVC and reinfusing in IVC, or one dual lumen cannula inserted in right jugular vein is all possible cannulation strategies. Independent of cannulation strategy there will be a risk of recirculation. Efficiency can be reasonable in either strategy if the cannulas are carefully positioned and monitored during the dynamic procedure of pulmonary disease. The disadvantage draining from IVC only occurs when there is a need for converting from VV to veno-arterial (VA) ECMO, reinfusing in the femoral artery. Then draining from SVC is the most efficient strategy, draining low saturated venous blood, and also means low risk of dual circulation.