INTRODUCTION
When veno-venous extracorporeal membrane oxygenation (VV-ECMO) is applied to a patient with severe respiratory failure, an optimal cannulation technique is essential to minimize recirculation.1 Recently, a dual lumen cannula for VV-ECMO was reported that it was simple and useful for reducing recirculation.2, 3 The right internal jugular and right common femoral veins are used in most common for the two vessel cannulation technique. However, the femoral to internal jugular VV-ECMO configuration with drainage and return ports in the inferior vena cava (IVC) and superior vena cava (SVC), respectively, leads to recirculation because the infusion jet is directed toward the drainage port. On the other hand, if the drainage cannula is positioned at low level of right atrium (RA) for decreasing recirculation, flow disturbance due to drainage chattering from changing intrathoracic or intraabdominal pressure can occur, can be fatal when a patient is wholly dependent on VV-ECMO. We report a case in which drainage chattering was eliminated and recirculation were decreased by repositioning the drainage and return cannula in a patient with VV ECMO flow disturbance when intrathoracic pressure was increased.