Background: Cardiac injury has been described in children with both acute COVID-19 and the multisystem inflammatory syndrome in children (MIS-C). Strain has been shown to be a sensitive measure of systolic function and can be used for detecting subclinical left ventricular (LV) dysfunction. We sought to describe strain findings in both groups on initial presentation and outpatient follow up. Methods: A retrospective study analyzing echocardiograms of all patients presenting with acute COVID-19 infection and MIS-C at our institution between March 2020 and December 2020 was performed. TOMTEC software was used for strain analysis in both study groups (COVID-19 and MIS-C) and age matched healthy controls. Regional strain was obtained and comparison amongst groups was performed using the Mann-Whitney U test. Strain was compared against LV ejection fraction (EF) as measured by 5/6 area length method. Results: 45 patients (34 MIS-C and 11 COVID-19) met inclusion criteria. There was a statistically significant decrease in LV longitudinal strain (p <0.001), LV circumferential strain (p <0.001) and left atrial strain (p = 0.014) in the MIS-C group when compared to the control group. There was a statistically significant decrease in LV longitudinal strain (p = 0.028) in the acute COVID-19 group. All patients with abnormal LVEF had abnormal strain. However 14 patients (41%) in the MIS-C group and 3 (27%) in the acute COVID-19 group had preserved LVEF but abnormal strain. Abnormal strain persisted in one-third of patients in the MIS-C and acute COVID-19 groups on outpatient follow up. Conclusion: Patients with MIS-C and acute COVID-19 can develop myocardial dysfunction as seen by abnormal strain. Strain may provide an additional tool in detecting subtle myocardial dysfunction. It can be routinely employed at diagnosis and at follow up evaluation of these patients.

Diagnosis of anomalous origin of the right subclavian artery (AORSA) from the right pulmonary artery (RPA) is usually made using CT or invasive angiography. We report a patient diagnosed using transthoracic echocardiography (TTE). A newborn girl prenatally known to have d-TGA presented with cyanosis sparing the right hemithorax and arm. Oxygen saturations on the right hand were persistently higher than on the right ear and other extremities. Repeat TTE using a modified echocardiographic imaging plane allowed for full visualization of the entire subclavian artery course, revealing AORSA from RPA. We discuss further the approach to echocardiographic diagnosis and surgical implications.

We report a case of a 17-year-old healthy male presenting with multisystem hyperinflammatory shock temporally associated with COVID-19. Cardiac involvement was suspected based on evidence of significant cardiac injury (elevated cardiac biomarkers, electrocardiographic and echocardiographic abnormalities). Cardiac magnetic resonance imaging was performed demonstrating global biventricular systolic dysfunction, as well as a small area of T2 hyperintensity and mid wall late gadolinium enhancement. This case discusses the varied cardiac involvement in pediatric patients with COVID-19 infection and highlights that cardiac injury is not just limited to hyperinflammatory syndrome related global dysfunction but a more focal myocarditis can also be seen.