Commotio cordis as cause of sudden cardiac death associated with chest trauma

The review describes a rarely occurring state of commotio cordis (CC) — ventricular fibrillation (VF), associated with unintentional blunt impact on the anterior thoracic wall in the absence of structural damage to the heart. The development of VF is based on the coincidence of the time of a closed breast trauma with a vulnerable period during early repolarization (the so-called "vulnerability window"). More often, death occurs instantly or in the coming minutes of a post-traumatic period. CC is more common in male adolescents and seems to be the second leading cause of sudden death in young athletes. It is possible to save the victim with cardiorespiratory resuscitation or defibrillation only in 25–28 % of cases. High mortality is explained by the fact that victims often do not have time to receive immediate medical care. It is necessary to inform the population, medical community and athletes about importance to avoid hitting the heart. As a preventive measure in some sports, chest protectors are used. Information about the potential danger of blows to the heart area should be provided to the attention of athletes involved, since even an unintentional mild blow can provoke a life-threatening arrhythmia. Having access to defibrillators at sporting events, teaching people to use them and to realize the cardio-pulmonary resuscitation measures can improve the survival of the CC victims.

1. Maron BJ, Estes NA 3rd. Commotio cordis. N Engl J Med. 2010; 362(10):917-27. DOI: 10.1056/NEJMra0910111.

2. Kelli M. Death touch: science behind the legend of Dim-Mak. Boulder, CO: Paladin Press, 2001. P. 184.

3. Maron BJ, Poliac LC, Kaplan JA, et al. Blunt impact to the chest leading to sudden death from cardiac arrest during sports activities. N Engl J Med. 1995; 333(6):337–342. DOI: 10.1056/NEJM199508103330602.

4. Maron BJ, Gohman TE, Kyle SB, et al. Clinical profile and spectrum of commotio cordis. JAMA. 2002; 287(9):1142–1146. DOI: 10.1001/jama.287.9.1142.

5. Maron BJ, Doerer JJ, Haas TS, et al. Sudden deaths in young competitive athletes: analysis of 1866 deaths in the United States, 1980–2006. Circulation. 2009; 119(8):1085–1092. DOI: 10.1161/CIRCULATIONAHA.108.804617.

6. Maron BJ, Ahluwalia A, Haas TS, et al. Global epidemiology and demographics of commotio cordis. Heart Rhythm. 2011; 8(12):1969–1971. DOI: 10.1016/j.hrthm.2011.07.014.

7. Harmon KG, Drezner JA, Maleszewski JJ, et al. Pathogeneses of sudden cardiac death in national collegiate athletic association athletes. Circ Arrhythm Electrophysiol. 2014; 7(2):198–204. DOI: 10.1161/CIRCEP.113.001376.

8. Kolkin YG, Vatutin NT, Momot NV, et al. “Contusio” and “commotio” cordis. The similarities and differences. Archive of Clinical and Experimental Medicine. 2020; 29(3):300–308. In Russian.

9. Jones LA, Sullivan RW. Ventricular Tachycardia: A Rare Commotio Cordis Presentation. Pediatr Emerg Care. 2017; 33(2):109–111. DOI: 10.1097/PEC.0000000000000685.

10. Maron BJ, Haas TS, Ahluwalia A, et al. Increasing survival rate from commotio cordis. Heart Rhythm. 2013; 10(2):219–223. DOI: 10.1016/j.hrthm.2012.10.034.

11. Maron BJ, Pelliccia A. The heart of trained athletes: cardiac remodeling and the risks of sports, including sudden death. Circulation. 2006; 114(15):1633–1644. DOI: 10.1161/CIRCULATIONAHA.106.613562.

12. Schlomka G. Expertise on a case of commotio cordis. Dtsch. Gesundheitsw. 1953; 8(1):11–12. In German [Schlomka G. Begutachtung eines Falles von Commotio cordis [Expertise on a case of commotio cordis]. Dtsch Gesund-heitsw. 1953 Jan 1;8(1):11–12].

13. Link MS. Commotio cordis: ventricular fibrillation triggered by chest impact-induced abnormalities in repolarization. Circ Arrhythm Electrophysiol. 2012; 5(2):425–432. DOI: 10.1161/CIRCEP.111.962712.

14. Madias C, Maron BJ, Weinstock J, et al. Commotio cordis--sudden cardiac death with chest wall impact. J Cardiovasc Electrophysiol. 2007; 18(1):115–122. DOI: 10.1111/j.1540-8167.2006.00684.x.

15. Guthrie K. Case of Commotio Cordis. Life in the Fast Lane (LITFL) Library, 2019.

16. Link MS, Maron BJ, Wang PJ, et al. Upper and lower limits of vulnerability to sudden arrhythmic death with chest-wall impact (commotio cordis). J Am Coll Cardiol. 2003; 41(1):99–104. DOI: 10.1016/s0735-1097(02)02669-4.

17. Kalin J, Madias C, Alsheikh-Ali AA, et al. Reduced diameter spheres increases the risk of chest blow-induced ventricular fibrillation (commotio cordis). Heart Rhythm. 2011; 8(10):1578–1581. DOI: 10.1016/j.hrthm.2011.05.009.

18. Makarov LM. Sport and sudden death in children. Rossiyskiy Vestnik Perinatologii i Pediatrii=Russian Bulletin of Perinatology and Pediatrics. 2017; 62(1):40–46. In Russian.

19. Kohl P, Nesbitt AD, Cooper PJ, Lei M. Sudden cardiac death by Commotio cordis: role of mechanoelectric feedback. Cardiovasc Res. 2001; 50(2):280–289. DOI: 10.1016/s0008-6363(01)00194-8.

20. Bode F, Franz MR, Wilke I, et al. Ventricular fibrillation induced by stretch pulse: implications for sudden death due to commotio cordis. J Cardiovasc Electrophysiol. 2006; 17(9):1011–1017. DOI: 10.1111/j.1540-8167.2006.00547.x.

21. Madias C, Maron BJ, Supron S, et al. Cell membrane stretch and chest blow-induced ventricular fibrillation: commotio cordis. J Cardiovasc Electrophys-iol. 2008; 19(12):1304–1309. DOI: 10.1111/j.1540-8167.2008.01267.x.

22. Link MS, Maron BJ, Wang PJ, et al. Reduced risk of sudden death from chest wall blows (commotio cordis) with safety baseballs. Pediatrics. 2002; 109(5):873–877. DOI: 10.1542/peds.109.5.873.

23. Lupariello F, Di Vella G. The role of the autopsy in the diagnosis of commotio cordis lethal cases: Review of the literature. Leg Med (Tokyo). 2019; 38:73–76. DOI: 10.1016/j.legalmed.2019.04.007.

24. Geddes LA, Roeder RA. Evolution of our knowledge of sudden death due to commotio cordis. Am J Emerg Med. 2005; 23(1):67–75. DOI: 10.1016/j.ajem.2003.12.023.

25. Maron BJ, Haas TS, Ahluwalia A, et al. Increasing survival rate from commotio cordis. Heart Rhythm. 2013; 10(2):219–23. DOI: 10.1016/j.hrthm.2012.10.034.

26. Link MS, Estes NAM 3rd, Maron BJ. Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 13: Commotio Cordis: A Scientific Statement From the American Heart Association and American College of Cardiology. J Am Coll Cardiol. 2015; 66(21):2439–2443. DOI: 10.1016/j.jacc.2015.09.045.