Cardiovascular Sequelae After SARS-CoV-2 in Children: From Myocardial Injury to Dysautonomia and Implications for Phenotype-Guided Follow-Up

To summarise current paediatric evidence on long-term cardiovascular sequelae after SARS-CoV-2 infection, with particular emphasis on the place of multisystem inflammatory syndrome in children (MIS-C), persistent subclinical myocardial abnormalities and autonomic dysfunction. A comprehensive literature search of PubMed and Scopus was conducted for studies published online or in print between January 2020 and 30 May 2026. Eligible studies included original research reporting cardiovascular, autonomic, or exercise-related outcomes in children after SARS-CoV-2 infection or MIS-C, with a minimum follow-up of four weeks. Studies across the full spectrum of acute disease severity were considered. Owing to substantial heterogeneity in study design, patient populations, and outcome definitions, a narrative rather than systematic review approach was adopted. Across paediatric cohorts, overt cardiac dysfunction after MIS-C usually resolves and conventional medium-term outcomes are generally reassuring. However, a subset of children show persistent abnormalities on strain imaging or cardiac magnetic resonance despite normalisation of standard echocardiographic findings, and the clinical significance of these abnormalities remains uncertain. In parallel, growing evidence indicates that autonomic dysfunction contributes to persistent symptoms such as palpitations, orthostatic complaints, fatigue, and exercise intolerance, particularly when structural cardiac evaluation is unremarkable. Current studies are limited by heterogeneity in phenotype, timing of follow-up and diagnostic protocols. Across paediatric cohorts spanning mild acute SARS-CoV-2 infection to severe MIS-C, overt cardiac dysfunction generally resolved and conventional medium-term outcomes were reassuring. However, selected cohorts reported persistent abnormalities on strain imaging or CMR, while their prognostic significance remained uncertain.