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INTRODUCTION: Multisystem Inflammatory Syndrome in Children (MIS-C) associated with COVID-19 (SARS-CoV-2) has been described in the pediatric population These children present with symptomatology similar to Kawasaki disease/toxic shock syndrome with tachycardia, fever, hypotension, rash, abdominal pain, and depressed myocardial function Treatment varies, with most centers describing supportive care and isolated reports of extracorporeal support We present three cases of severe MIS-C with cardiogenic shock treated with venoarterial ECMO with excellent results METHODS: We report three cases of MIS-C with myocardial involvement in previously healthy children, all of whom were SARS-CoV-2 IgG positive Patient 1, a 6-yearold female, suffered a cardiac arrest prior to cannulation All three patients had severely depressed myocardial function and arrhythmia, as well as evidence of multiple organ failure with severely elevated systemic inflammatory markers The children were treated with intravenous immunoglobulin (IVIG), remdesivir, and methylprednisolone Two patients received infliximab, while the other received tocilizumab Patients 1 and 2 had features of Kawasaki disease, with significant coronary artery dilatation on echocardiogram, so were treated with moderate dose aspirin Of note, Patients 1 and 2 were treated with aspirin prior to cannulation and were successfully anticoagulated using unfractionated heparin without clotting issues Patient 3 did not have coronary dilation on echocardiogram, so was not treated with aspirin Patient 3 had heparin resistance and developed clots in the arterial cannula within hours of initiation, requiring a circuit change and transition to bivalirudin for anticoagulation All three patients had significant improvement in cardiac function within 48 hours after ECMO initiation, and all were decannulated and discharged home without serious sequelae All three patients now have normal cardiac function on echocardiography and no residual end organ effects RESULTS: This case series highlights a novel severe clinical presentation of COVID-19 in pediatric patients These cases describe the successful use of ECMO to support children with MIS-C and treat the underlying inflammatory response with complete symptom resolution and normalization of cardiac function |
