A fter 3 years into the pandemic, pediatricians have grown accustomed to the fact that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes either acute COVID-19 disease or multisystem inflammatory syndrome in children (MIS-C). At their core, these are two different disease processes with the former a disorder of primary respiratory pathophysiology and the latter, a syndrome characterized by hyperinflammation and multiple organ dysfunction, especially cardiac disease (1, 2). Unsurprisingly, both can lead to fulminant organ failure requiring extracorporeal mechanical support, but as the disease processes are driven by different organ systems, the indications and modalities of support are different (2, 3). This is in stark contrast to adults with acute SARS-CoV-2 infection, who required extracorporeal membrane oxygenation (ECMO) almost exclusively for respiratory failure (4, 5). Sadly, there is a large gap in knowledge for ECMO in pediatric patients with SARS-CoV-2-associated disease and the literature is extremely limited (6). Thus, it is imperative for this disease and potentially future pandemics with divergent pathophysiologic processes to best understand who, when, and how to deploy a scarce and important resource to guide clinical decision-making.In this issue of Pediatric Critical Care Medicine, Bembea et al (7) describe the characteristics of children and adolescents with SARS-CoV-2 who required ECMO support. While there have been several large database studies and meta-analyses examining adults treated with ECMO for acute COVID-19, this is the first study to examine a large cohort of pediatric patients (4,5,8). This is an important undertaking, and the results are informative.Overall, Bembea et al (7) describe ECMO as rarely used for acute COVID-19 (5.9%) or MIS-C (2.4%); numbers comparable to adult ICU patients (9). Patients with acute COVID-19 disease were supported with venovenous strategies, while patients with MIS-C were supported using venoarterial cannulation. This is not surprising, as MIS-C is a disease of inflammation and hemodynamic compromise (2). These patients had an overall low mortality rate compared to other diagnoses requiring venoarterial ECMO; very similar to the mortality rate in myocarditis (10, 11). Furthermore, 11% of patients in the MIS-C ECMO *See also p. 356.