Commotio Cordis -- Sudden Cardiac Death With Chest Wall Impact

Christopher Madias, M.D.; Barry J. Maron, M.D.; Jonathan Weinstock, M.D.; N. A. Mark Estes III, M.D.; Mark S. Link, M.D.

Disclosures

J Cardiovasc Electrophysiol. 2007;18(1):115-122. 

In This Article

Abstract and Introduction

Commotio cordis (CC), sudden death as a result of a blunt, often innocent-appearing chest wall blow, is being reported with increasing frequency. The clinical spectrum is diverse; however, a substantial number of cases occur in youth athletics. In events that occur during sport, victims are struck by projectiles regarded as standard implements of the game. Sudden death is instantaneous and victims are most often found in ventricular fibrillation (VF). Overall survival is poor; however, successful resuscitation can be achieved with early defibrillation. Autopsy is notable for the absence of any significant cardiac or thoracic injury. Development of an experimental model has allowed for substantial insights into the underlying mechanisms of sudden death. In anesthetized juvenile swine, induction of VF is instantaneous following chest wall blows occurring during a vulnerable window before the T wave peak. Crucial variables including the velocity of impact, impact location, and hardness of the impact object have been identified. Rapid left ventricular (LV) pressure rise following chest impact likely results in activation of ion channels via mechano-electric coupling. The generation of inward current via mechano-sensitive ion channels likely results in augmentation of repolarization and nonuniform myocardial activation, and is the cause of premature ventricular depolarizations that are triggers of VF in CC. While softer-than-standard safety baseballs reduce the risk of CC, commercially available chest protectors are ineffective in preventing CC. The development of more effective chest protectors and more widespread use of automated external defibrillators at youth sporting events are needed.

Although once thought to be exceedingly rare, commotio cordis (CC)—sudden cardiac death as a result of a blunt and often innocent-appearing chest wall blow—is being reported with increasing frequency.[1,2,3,4,5,6,7,8] Currently, CC ranks as the second leading cause of death in youth athletics, and it is apparent that this tragic event has previously been unrecognized and underreported.[1,4] More than 180 cases have now been recorded in the U.S. Commotio Cordis Registry, with most victims being young males (median age 14 years).[1,9]

Derived from Latin and meaning disturbance of the heart, CC events are due to low impact, nonpenetrating chest wall blows, most of which are not of sufficient force to cause any significant structural damage to the ribs, sternum, or heart. This characteristic differentiates CC from contusio cordis, in which morbidity and mortality are seen as direct results of myocardial tissue damage, often due to high impact blows that also result in injury to the overlying structures of the chest and thorax. Although the clinical context is quite diverse, many instances of CC occur as a result of chest impact with small dense projectiles used in organized sports, such as baseball, hockey, and lacrosse.[1,3,10] Cardiac arrest is virtually instantaneous and resuscitation is more difficult than expected. There have been a number of recent insights into the mechanism of these tragic events. It is now apparent that CC is a primary electrical event resulting in the induction of ventricular fibrillation (VF), likely due to activation of mechano-sensitive ion channels through the phenomenon of mechano-electric coupling.[4,11,12] This article reviews several aspects of CC, including its historical perspective, its clinical spectrum, recent pathophysiologic insights, and its prevention and treatment.

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