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Objective: Identify associations between cannulation approach and mortality in neonates who received ECMO support for respiratory failure., Study Design: A retrospective analysis of neonates receiving ECMO for respiratory indications at a single quaternary-referral NICU. Associations between cannulation approach and mortality were assessed after adjustment for Neo-RESCUERS score. Cox Proportional Hazards (CPH) model was used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for each variable and outcome., Results: Among 244 neonates, overall survival was 88%, with 71% undergoing VV cannulation. After adjusting for Neo-RESCUERS score, VA cannulation was associated with higher mortality during ECMO when compared with VV cannulation (HR 4.189, 95% CI 1.480-11.851, P = 0.0069). Disease-specific comparisons revealed no statistical difference in Neo-RESCUERS score between VA and VV cohorts; however, VA cannulation was associated with higher ECMO mortality for neonates with congenital diaphragmatic hernia (50% vs. 5.5%, Χ 2  = 8.5965, P = 0.0034) and PPHN (20% vs. 1.8%, Χ 2  = 9.1047, P = 0.0025) when compared with VV cannulation., Conclusion: VA cannulation was associated with increased mortality in neonates while on ECMO for respiratory failure, which was independent of illness severity., (© 2022. The Author(s), under exclusive licence to Springer Nature America, Inc.)