Pediatric Acute Heart Failure and SARS-CoV-2 Infection

Quick Takes

  • Severe cardiac involvement can be seen with the multisystem inflammatory syndrome in children (MIS-C), with most patients requiring inotropic support and a significant proportion requiring mechanical circulatory support.
  • BNP was often quite elevated and may be helpful in identifying cardiac involvement in patients with prolonged febrile illnesses.
  • Treatment with intravenous immunoglobulin appears associated with recovery of left ventricular systolic function in MIS-C.

Study Questions:

What are the clinical characteristics, treatment, and outcomes of cardiac injury and myocarditis in pediatric patients with the multisystem inflammatory syndrome (MIS-C) associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection?


A retrospective review was performed at 14 European centers. Inclusion criteria included the presence of fever (>38.5°C [>101.3°F]), cardiogenic shock, or acute left ventricular (LV) dysfunction (LV ejection fraction [LVEF] <50%) with inflammatory state (C-reactive protein >100 mg/ml).


A total of 35 children were identified and included in the study. The vast majority of patients (88%) tested positive for SARS-CoV-2 infection with 40% having positive polymerase chain reaction (PCR) at the time of admission and 86% of the entire cohort with positive antibody assays. EF was <30% in one third of patients, while 80% required inotropic support and 28% required extracorporeal membrane oxygenation (ECMO). Mean B-type natriuretic peptide (BNP) was elevated at 5284 pg/ml. All patients were treated with intravenous immune globulin, with one third of patients receiving adjunctive steroids. LV function was restored in 25 of 35 patients. All patients requiring ECMO were successfully weaned, and there were no deaths.


The authors concluded that children may experience acute cardiac decompensation due to severe inflammatory state following SARS-CoV-2 infection. Treatment with immune globulin appears to be associated with recovery of LV systolic function.


Although it initially appeared that school-aged children are not greatly impacted by SARS-CoV-2 infection, there have been increasing concerns about a related multisystem inflammatory condition. This multicenter report with predominantly French centers (one center in Switzerland) describes experience with cardiac involvement of this disease process. Pro-BNP was often severely elevated in affected patients, and participating centers ultimately employed pro-BNP in the assessment of children in the emergency room with prolonged and unexplained fever. Although MIS-C bears some similarities to Kawasaki disease, coronary involvement does not appear to be a hallmark of the condition, at least in the early stages. In this cohort, coronary dilatation was seen in 17% of patients, with no coronary aneurysms seen at the time of publication of the manuscript. Although MIS-C is associated with severe cardiac involvement, prognosis in this series was good, with all patients successfully weaning from ECMO, most patients normalizing LV function, and no mortality.

Clinical Topics: Heart Failure and Cardiomyopathies, Prevention, Acute Heart Failure, Heart Failure and Cardiac Biomarkers

Keywords: Coronavirus, COVID-19, C-Reactive Protein, Extracorporeal Membrane Oxygenation, Fever, Heart Failure, Immunoglobulins, Intravenous, Inflammation, Myocarditis, Natriuretic Peptide, Brain, Pediatrics, SARS Virus, Secondary Prevention, Shock, Cardiogenic, Stroke Volume

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