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Multisystem inflammatory syndrome in children (MIS-C) is one of the most significant sequela of coronavirus disease 2019 in children. Emerging literature has described myocardial dysfunction in MIS-C patients using traditional and two-dimensional speckle tracking echocardiography in the acute phase. However, data regarding persistence of subclinical myocardial injury after recovery is limited. We aimed to detect these changes with deformation imaging, hypothesizing that left ventricular global longitudinal (GLS) and circumferential strain (GCS) would remain impaired in the chronic phase despite normalization of ventricular function parameters assessed by two-dimensional echocardiography. A retrospective, single-institution review of 22 patients with MIS-C was performed. Fractional shortening, GLS, and GCS, along with regional longitudinal (RLS) and circumferential strain (RCS) were compared across the acute, subacute, and chronic timepoints (presentation, 14-42, and > 42 days, respectively). Mean GLS improved from − 18.4% in the acute phase to − 20.1% in the chronic phase (p = 0.4). Mean GCS improved from − 19.4% in the acute phase to − 23.5% in the chronic phase (p = 0.03). RCS and RLS were impaired in the acute phase and showed a trend towards recovery by the chronic phase, with the exception of the basal anterolateral segment. In our longitudinal study of MIS-C patients, GLS and GCS were lower in the acute phase, corroborating with left ventricular dysfunction by traditional measures. Additionally, as function globally recovers, GLS and GCS also normalize. However, some regional segments continue to have decreased strain values which may be an important subclinical marker for future adverse events. KeywordsCoronavirus disease 2019 (COVID-19) • Multisystem inflammatory syndrome in children (MIS-C) • Twodimensional speckle tracking echocardiography (2D-STE) • Longitudinal strain • Circumferential strain Abbreviations MIS-C Multisystem inflammatory syndrome in children COVID-19 Coronavirus disease 2019 2D-STE Two-dimensional speckle tracking echocardiography GLS Global longitudinal strain GCS Global circumferential strain RLS Regional longitudinal strain RCS Regional circumferential strain FS Fractional shortening KD Kawasaki disease PICU Pediatric intensive care unit * Michael He

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Purpose of review COVID-19-related guidance has changed dramatically since the onset of the pandemic. Awareness of data regarding prevention of disease, the cardiac manifestations and treatment of acute COVID-19 and multisystem inflammatory syndrome in children, and return to physical activity following an infection allows for appropriate adjustment of current care models and guides future study. Recent findingsSevere acute respiratory syndrome coronavirus 2 transmission can be reduced using various mitigation strategies, though their effectiveness differs based on viral prevalence. The risk of severe disease during acute COVID-19 infection is low in children and adolescents, though specific risk factors have been identified. COVID-19 vaccination significantly decreases the risk of severe disease and poor outcomes. Regular physical activity positively affects well being and has been a focus of recent guidance regarding well tolerated return to activities following an infection.

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