Pathophysiology, Prevention, and Treatment of Commotio Cordis

Invasive Electrophysiology and Pacing (EK Heist, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Invasive Electrophysiology and Pacing

Abstract

Commotio cordis is increasing described and it is now clear that this phenomenon is an important cause of sudden cardiac death on the playing field. Victims are predominantly young, male, and struck in the left chest with a ball. An animal model has been developed and utilized to explore the important variables and mechanism of commotio cordis. Impact during a narrow window of repolarization causes ventricular fibrillation. Other important variables include location, velocity, shape, and hardness of the impact object. Biological characteristics such as gender, pliability of the chest wall, and genetic susceptibility also play a role in commotio cordis. The mechanism of ventricular fibrillation appears to be an increase in heterogeneity of repolarization caused by induced abnormalities of ion channels activated by abrupt increases in left ventricular pressure. In the setting of altered repolarization a trigger of ventricular depolarization (premature ventricular depolarization caused directly by the chest blow) initiates a spiral wave that quickly breaks down into ventricular fibrillation. Prevention of commotio cordis is possible. Improved recognition and resuscitation have led to an improvement in outcome.

Keywords

Commotio cordis Athlete Sudden cardiac death Ventricular fibrillation Sports 

Notes

Compliance with Ethics Guidelines

Conflict of Interest

Mark S. Link has a patent without any financial payment to him on chest wall protection.

Human and Animal Rights and Informed Consent

All animal research described was approved by the Institutional Animal Care and Use Committee of the Tufts Medical Center in conformity with the regulations of the Association for Assessment and Accreditation of Laboratory Animal Care.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.
    Maron BJ. Sudden death in young athletes. N Engl J Med. 2003;349:1064–75.PubMedCrossRefGoogle Scholar
  2. 2.
    Maron BJ, Poliac LC, Kaplan JA, Mueller FO. Blunt impact to the chest leading to sudden death from cardiac arrest during sports activities. N Engl J Med. 1995;333:337–42.PubMedCrossRefGoogle Scholar
  3. 3.
    Maron BJ, Link MS, Wang PJ, Estes 3rd NA. Clinical profile of commotio cordis: an under appreciated cause of sudden death in the young during sports and other activities. J Cardiovasc Electrophysiol. 1999;10:114–20.PubMedCrossRefGoogle Scholar
  4. 4.
    Link MS. Commotio cordis, sudden death due to chest wall impact in sports. Heart. 1999;81:109–10.PubMedCentralPubMedCrossRefGoogle Scholar
  5. 5.
    Haq CL. Sudden death due to low-energy chest-wall impact (commotio cordis). N Engl J Med. 1998;339:1399.PubMedGoogle Scholar
  6. 6.
    Link MS, Estes NA. Athletes and arrhythmias. J Cardiovasc Electrophysiol. 2010;21:1184–9.PubMedCrossRefGoogle Scholar
  7. 7.
    Madias C, Maron BJ, Weinstock J, Estes 3rd NA, Link MS. Commotio cordis–sudden cardiac death with chest wall impact. J Cardiovasc Electrophysiol. 2007;18:115–22.PubMedCrossRefGoogle Scholar
  8. 8.
    Maron BJ, Gohman TE, Kyle SB, Estes 3rd NA, Link MS. Clinical profile and spectrum of commotio cordis. JAMA. 2002;287:1142–6.PubMedCrossRefGoogle Scholar
  9. 9.
    Maron BJ, Poliac LC, Kyle SB. Clinical profile of commotio cordis: an under-appreciated cause of sudden cardiac death in the young during sporting activities. Circulation. 1997;96:1755. Abstract.CrossRefGoogle Scholar
  10. 10.
    Maron BJ, Strasburger JF, Kugler JD, Bell BM, Brodkey FD, Poliac LC. Survival following blunt chest impact induced cardiac arrest during sports activities in young athletes. Am J Cardiol. 1997;79:840–1.PubMedCrossRefGoogle Scholar
  11. 11.
    Maron BJ, Shirani J, Poliac LC, Mathenge R, Roberts WC, Mueller FO. Sudden death in young competitive athletes: clinical, demographic, and pathologic profiles. JAMA. 1996;276:199–204.PubMedCrossRefGoogle Scholar
  12. 12.
    Maron BJ, Estes 3rd NA. Commotio cordis. N Engl J Med. 2010;362:917–27.PubMedCrossRefGoogle Scholar
  13. 13.
    Maron BJ, Mitten MJ, Burnett CG. Criminal consequences of commotio cordis. Am J Cardiol. 2002;89:210–3.PubMedCrossRefGoogle Scholar
  14. 14.
    Swift EM. A cruel blow; a seemingly harmless slash to the chest resulted in the death of a hockey player in Italy. Now, Jimmy Boni will go on trial for manslaughter. Sports Illustrated 1993:66–79.Google Scholar
  15. 15.
    Link MS, Maron BJ, Wang PJ, VanderBrink BA, Zhu W, Estes 3rd NA. Upper and lower limits of vulnerability to sudden arrhythmic death with chest-wall impact (commotio cordis). J Am Coll Cardiol. 2003;41:99–104.PubMedCrossRefGoogle Scholar
  16. 16.
    Knollmann BC, Roden DM. A genetic framework for improving arrhythmia therapy. Nature. 2008;451:929–36.PubMedCrossRefGoogle Scholar
  17. 17.
    Alsheikh-Ali AA, Madias C, Supran S, Link MS. Marked variability in susceptibility to ventricular fibrillation in an experimental commotio cordis model. Circulation. 2010;122:2499–504.PubMedCrossRefGoogle Scholar
  18. 18.
    Roden DM. Drug-induced prolongation of the QT interval. N Engl J Med. 2004;350:1013–22.PubMedCrossRefGoogle Scholar
  19. 19.•
    Maron BJ, Haas TS, Ahluwalia A, Garberich RF, Mark Estes NA, Link MS. Increasing survival rate from commotio cordis. Heart Rhythm. 2013;10:219–23. This manuscript shows that survival in human commotio cordis victims is increasing; in the preent era survival is now up to 60 %.PubMedCrossRefGoogle Scholar
  20. 20.
    Link MS, Wang PJ, Pandian NG, et al. An experimental model of sudden death due to low-energy chest-wall impact (commotio cordis). N Engl J Med. 1998;338:1805–11.PubMedCrossRefGoogle Scholar
  21. 21.•
    Link MS. Commotio cordis: ventricular fibrillation triggered by chest impact-induced abnormalities in repolarization. Circ Arrhythm Electrophysiol. 2012;5:425–32.PubMedCrossRefGoogle Scholar
  22. 22.
    Link MS, Maron BJ, VanderBrink BA, et al. Impact directly over the cardiac silhouette is necessary to produce ventricular fibrillation in an experimental model of commotio cordis. J Am Coll Cardiol. 2001;37:649–54.PubMedCrossRefGoogle Scholar
  23. 23.
    Link MS, Maron BJ, Wang PJ, Pandian NG, VanderBrink BA, Estes 3rd NA. Reduced risk of sudden death from chest wall blows (commotio cordis) with safety baseballs. Pediatrics. 2002;109:873–7.PubMedCrossRefGoogle Scholar
  24. 24.•
    Kalin J, Madias C, Alsheikh-Ali AA, Link MS. Reduced diameter spheres increases the risk of chest blow-induced ventricular fibrillation (commotio cordis). Heart Rhythm. 2011;8:1578–81. This manuscript evaluates whether the diameter of the impact objects is an important variable in commotio cordis, and finds that reduced diameter spheres increase the odds of ventricular fibrillation with chest strikes.PubMedCrossRefGoogle Scholar
  25. 25.
    Link MS. Mechanically induced sudden death in chest wall impact. Progress of Biophysics Molecular Biological. 2003;82:175–86.CrossRefGoogle Scholar
  26. 26.
    Kohl P, Hunter P, Noble D. Stretch-induced changes in heart rate and rhythm: clinical observations, experiments and mathematical models. Progress of Biophysics Molecular Biological. 1999;71:91–138.CrossRefGoogle Scholar
  27. 27.
    Kohl P, Nesbitt AD, Cooper PJ, Lei M. Sudden cardiac death by Commotio cordis: role of mechanico-electrical feedback. Cardiovasc Res. 2001;50:280–9.PubMedCrossRefGoogle Scholar
  28. 28.
    Kohl P, Ravens U. Cardiac mechano-electric feedback: past, present, and prospect. Prog Biophys Mol Biol. 2003;82:3–9.PubMedCrossRefGoogle Scholar
  29. 29.
    Van Wagoner DR. Mechanosensitive gating of atrial ATP-sensitive potassium channels. Circ Res. 1993;72:973–83.PubMedCrossRefGoogle Scholar
  30. 30.
    Madias C, Maron BJ, Supron S, Estes 3rd NA, Link MS. Cell membrane stretch and chest blow-induced ventricular fibrillation: commotio cordis. J Cardiovasc Electrophysiol. 2008;19:1304–9.PubMedCrossRefGoogle Scholar
  31. 31.
    Link MS, Wang PJ, VanderBrink BA, et al. Selective activation of the K(+)(ATP) channel is a mechanism by which sudden death is produced by low-energy chest-wall impact (Commotio cordis). Circulation. 1999;100:413–8.PubMedCrossRefGoogle Scholar
  32. 32.
    Bode F, Franz MR, Wilke I, Bonnemeier H, Schunkert H, Wiegand UK. Ventricular fibrillation induced by stretch pulse: implications for sudden death due to commotio cordis. J Cardiovasc Electrophysiol. 2006;17:1011–7.PubMedCrossRefGoogle Scholar
  33. 33.
    Fabritz CL, Kirchhof PF, Behrens S, Zabel M, Franz MR. Myocardial vulnerability to T wave shocks: relation to shock strength, shock coupling interval, and dispersion of ventricular repolarization. J Cardiovasc Electrophysiol. 1996;7:231–42.PubMedCrossRefGoogle Scholar
  34. 34.
    Weinstock J, Maron BJ, Song C, Mane PP, Estes 3rd NA, Link MS. Failure of commercially available chest wall protectors to prevent sudden cardiac death induced by chest wall blows in an experimental model of commotio cordis. Pediatrics. 2006;117:e656–62.PubMedCrossRefGoogle Scholar
  35. 35.
    Viano DC, Bir CA, Cheney AK, Janda DH. Prevention of commotio cordis in baseball: an evaluation of chest wall protectors. J Trauma. 2000;49:1023–8.PubMedCrossRefGoogle Scholar
  36. 36.
    Marenco JP, Wang PJ, Link MS, Homoud MK, Estes 3rd NA. Improving survival from sudden cardiac arrest: the role of the automated external defibrillator. JAMA. 2001;285:1193–200.PubMedCrossRefGoogle Scholar
  37. 37.
    Drezner JA, Rogers KJ. Sudden cardiac arrest in intercollegiate athletes: detailed analysis and outcomes of resuscitation in nine cases. Heart Rhythm. 2006;3:755–9.PubMedCrossRefGoogle Scholar
  38. 38.
    Friedman FD, Dowler K, Link MS. A public access defibrillation programme in non-inpatient hospital areas. Resuscitation. 2006;69:407–11.PubMedCrossRefGoogle Scholar
  39. 39.
    Salib EA, Cyran SE, Cilley RE, Maron BJ, Thomas NJ. Efficacy of bystander cardiopulmonary resuscitation and out-of-hospital automated external defibrillation as life-saving therapy in commotio cordis. J Pediatr. 2005;147:863–6.PubMedCrossRefGoogle Scholar
  40. 40.
    Link MS, Maron BJ, Stickney RE, et al. Automated external defibrillator arrhythmia detection in a model of cardiac arrest due to commotio cordis. J Cardiovasc Electrophysiol. 2003;14:83–7.PubMedCrossRefGoogle Scholar
  41. 41.
    Association AH. Advanced Cardiovascular Life Support Provider Manual (American Heart Association, ACLS Provider Manual); 2006.Google Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  1. 1.The Cardiac Arrhythmia CenterTufts Medical CenterBostonUSA
  2. 2.Tufts Medical CenterBostonUSA

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