text: Cardiac manifestations in SARS CoV 2 associated multisystem inflammatory syndrome in children a comprehensive review and proposed clinical approach Initial reports on COVID 19 described children as largely spared from severe manifestations with only 2 6 of children requiring intensive care treatment However since mid April 2020 clusters of pediatric cases of severe systemic hyperinflammation and shock epidemiologically linked with COVID 19 have been reported This condition was named as SARS Cov 2 associated multisystem inflammatory syndrome in children and showed similarities to Kawasaki disease Here we present a narrative review of cases reported in literature and we discuss the clinical acute and follow up management of these patients Patients with SARS Cov 2 associated multisystem inflammatory syndrome frequently presented with persistent fever gastrointestinal symptoms polymorphic rash conjunctivitis and mucosal changes Elevated inflammatory markers and evidence of cytokine storm were frequently observed A subset of these patients also presented with hypotension and shock 20 100 from either acute myocardial dysfunction or systemic hyperinflammation vasodilation Coronary artery dilation or aneurysms have been described in 6 24 and arrhythmias in 7 60 Cardiac support immunomodulation and anticoagulation are the key aspects for the management of the acute phase Long term structured follow up of these patients is required due to the unclear prognosis and risk of progression of cardiac manifestations Conclusion Multisystem inflammatory syndrome is a novel syndrome related to SARS CoV 2 infection Evidence is still scarce but rapidly emerging in the literature Cardiac manifestations are frequent including myocardial and coronary involvement and need to be carefully identified and monitored over time What is Known Multisystem inflammatory syndrome in children MIS C has been described associated with SARS CoV 2 What is New Patients with MIS C often present with fever gastrointestinal symptoms and shock Cardiac involvement is found in a high proportion of these patients including ventricular dysfunction coronary artery dilation or aneurysm and arrhythmias Management is based on expert consensus and includes cardiac support immunomodulatory agents and anticoagulation Long term follow up is required due to the unclear prognosis and risk of progression of cardiac manifestation 