This editorial reviews the complexities of anticoagulation monitoring during extracorporeal membrane oxygenation (ECMO), emphasizing the balance between preventing thromboembolic events and minimizing hemorrhagic risks. Current tools like ACT, aPTT, and anti-factor Xa assays are evaluated for their efficacy and limitations. While aPTT remains widely used, anti-factor Xa is emerging as a promising alternative. The authors call for more research and advanced monitoring strategies to improve clinical outcomes.