Skip to main content
SpringerLink
Log in

Commotio Cordis

  • Chapter
  • First Online:
Textbook of Sports and Exercise Cardiology

  • 1282 Accesses

Abstract

Commotio cordis is an important cause of sudden cardiac arrest on the playing field in the US. In Europe it is condsidered rare. The difference is probably due to variation in sports between the continents and also that commotio cordis may be underrecognized in Europe; one particular reason why it is important to inform about the condition. Victims are predominantly young, male and struck in the left chest with a ball or during a body collision. An animal model has been utilized to explore and describe the important variables and mechanism of commotio cordis precisely. The model has provided substantial knowledge to the field of arrhythmias. 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. The induction 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 from the impact. 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.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 89.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 119.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 169.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Change history

  • 01 May 2021

    The original version of this chapter is revised as follows,

    Initially the chapter was published with the co-author name as Eric Solberg.

    Now chapter 26 and List of contributors, Table of contents in the Front matter was updated with the Author’s full name as Erik Ekker Solberg.

References

  1. Haq CL. Sudden death due to low-energy chest-wall impact (commotio cordis). N Engl J Med. 1998;339(19):1399.

    CAS  PubMed  Google Scholar 

  2. Link MS. Commotio cordis: sudden death due to chest wall impact in sports. Heart. 1999;81(2):109–10.

    CAS  PubMed  PubMed Central  Google Scholar 

  3. Link MS, Estes NA 3rd. Mechanically induced ventricular fibrillation (commotio cordis). Heart Rhythm. 2007;4(4):529–32.

    PubMed  Google Scholar 

  4. Link MS, Estes NA. Athletes and arrhythmias. J Cardiovasc Electrophysiol. 2010;21(10):1184–9.

    PubMed  Google Scholar 

  5. Maron BJ. Sudden death in young athletes. N Engl J Med. 2003;349(11):1064–75.

    CAS  PubMed  Google Scholar 

  6. Maron BJ, Link MS, Wang PJ, Estes NA 3rd. 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(1):114–20.

    CAS  PubMed  Google Scholar 

  7. 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(6):337–42.

    CAS  PubMed  Google Scholar 

  8. Maron BJ, Boren SD, Estes NA 3rd. Early descriptions of sudden cardiac death due to commotio cordis occurring in baseball. Heart Rhythm. 2010;7(7):992–3.

    PubMed  Google Scholar 

  9. Maron BJ, Gohman TE, Kyle SB, Estes NA 3rd, Link MS. Clinical profile and spectrum of commotio cordis. JAMA. 2002;287(9):1142–6.

    PubMed  Google Scholar 

  10. Maron BJ, Shirani J, Poliac LC, Mathenge R, Roberts WC, Mueller FO. Sudden death in young competitive athletes. Clinical, demographic, and pathological profiles. JAMA. 1996;276(3):199–204.

    CAS  PubMed  Google Scholar 

  11. 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(6):840–1.

    CAS  PubMed  Google Scholar 

  12. Maron BJ, Poliac LC, Kyle SB. Clinical profile of commotio cordis: an under-appreciated cause of sudden cardic death in the young during sporting activities. Circulation. 1997;96:I–755.

    Google Scholar 

  13. Maron BJ, Estes NA 3rd. Commotio cordis. N Engl J Med. 2010;362(10):917–27.

    CAS  PubMed  Google Scholar 

  14. Solberg EE, Embra BI, Borjesson M, Herlitz J, Corrado D. Commotio cordis—under-recognized in Europe?: a case report and review. Eur J Cardiovasc Prev Rehabil. 2011;18(3):378–83.

    PubMed  Google Scholar 

  15. Cooper S, Woodford NW, Maron BJ, Harris KM, Sheppard MN. A lethal blow to the chest as an underdiagnosed cause of sudden death in United Kingdom sports (football, cricket, rugby). Am J Cardiol. 2019;124(5):808–11.

    PubMed  Google Scholar 

  16. Goldenberg I, Moss AJ, Bradley J, Polonsky S, Peterson DR, McNitt S, et al. Long-QT syndrome after age 40. Circulation. 2008;117(17):2192–201.

    PubMed  Google Scholar 

  17. Zareba W, Moss AJ, Locati EH, Lehmann MH, Peterson DR, Hall WJ, et al. Modulating effects of age and gender on the clinical course of long QT syndrome by genotype. J Am Coll Cardiol. 2003;42(1):103–9.

    PubMed  Google Scholar 

  18. Gehi AK, Duong TD, Metz LD, Gomes JA, Mehta D. Risk stratification of individuals with the Brugada electrocardiogram: a meta-analysis. J Cardiovasc Electrophysiol. 2006;17(6):577–83.

    PubMed  Google Scholar 

  19. Knollmann BC, Roden DM. A genetic framework for improving arrhythmia therapy. Nature. 2008;451(7181):929–36.

    CAS  PubMed  Google Scholar 

  20. 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(24):2499–504.

    PubMed  Google Scholar 

  21. Roden DM. Drug-induced prolongation of the QT interval. N Engl J Med. 2004;350(10):1013–22.

    CAS  PubMed  Google Scholar 

  22. Link MS, Maron BJ, Wang PJ, VanderBrink BA, Zhu W, Estes NA 3rd. 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.

    PubMed  Google Scholar 

  23. Maron BJ, Haas TS, Ahluwalia A, Garberich RF, Estes NA 3rd, Link MS. Increasing survival rate from commotio cordis. Heart Rhythm. 2013;10(2):219–23.

    PubMed  Google Scholar 

  24. Link MS, Wang PJ, Pandian NG, Bharati S, Udelson JE, Lee MY, et al. An experimental model of sudden death due to low-energy chest-wall impact (commotio cordis). N Engl J Med. 1998;338(25):1805–11.

    CAS  PubMed  Google Scholar 

  25. Link MS. Commotio cordis: ventricular fibrillation triggered by chest impact-induced abnormalities in repolarization. Circ Arrhythm Electrophysiol. 2012;5(2):425–32.

    PubMed  Google Scholar 

  26. Link MS, Maron BJ, VanderBrink BA, Takeuchi M, Pandian NG, Wang PJ, 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(2):649–54.

    CAS  PubMed  Google Scholar 

  27. Weinstock J, Maron BJ, Song C, Mane PP, Estes NA 3rd, 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(4):e656–62.

    PubMed  Google Scholar 

  28. 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(10):1578–81.

    PubMed  Google Scholar 

  29. Link MS. Mechanically induced sudden death in chest wall impact (commotio cordis). Prog Biophys Mol Biol. 2003;82(1-3):175–86.

    PubMed  Google Scholar 

  30. Madias C, Maron BJ, Weinstock J, Estes NA 3rd, Link MS. Commotio cordis—sudden cardiac death with chest wall impact. J Cardiovasc Electrophysiol. 2007;18(1):115–22.

    PubMed  Google Scholar 

  31. Kohl P, Ravens U. Cardiac mechano-electric feedback: past, present, and prospect. Prog Biophys Mol Biol. 2003;82(1-3):3–9.

    PubMed  Google Scholar 

  32. Kohl P, Hunter P, Noble D. Stretch-induced changes in heart rate and rhythm: clinical observations, experiments and mathematical models. Prog Biophys Mol Biol. 1999;71(1):91–138.

    CAS  PubMed  Google Scholar 

  33. Kohl P, Nesbitt AD, Cooper PJ, Lei M. Sudden cardiac death by Commotio cordis: role of mechano-electric feedback. Cardiovasc Res. 2001;50(2):280–9.

    CAS  PubMed  Google Scholar 

  34. Link MS, Wang PJ, VanderBrink BA, Avelar E, Pandian NG, Maron BJ, 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(4):413–8.

    CAS  PubMed  Google Scholar 

  35. Madias C, Maron BJ, Supron S, Estes NA 3rd, Link MS. Cell membrane stretch and chest blow-induced ventricular fibrillation: commotio cordis. J Cardiovasc Electrophysiol. 2008;19(12):1304–9.

    PubMed  Google Scholar 

  36. Van Wagoner DR. Mechanosensitive gating of atrial ATP-sensitive potassium channels. Circ Res. 1993;72(5):973–83.

    PubMed  Google Scholar 

  37. Stout CW, Maron BJ, Vanderbrink BA, Estes NA 3rd, Link MS. Importance of the autonomic nervous system in an experimental model of commotio cordis. Med Sci Monit. 2007;13(1):BR11–5.

    PubMed  Google Scholar 

  38. 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(9):1011–7.

    PubMed  Google Scholar 

  39. 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(3):231–42.

    CAS  PubMed  Google Scholar 

  40. Viano DC, Bir CA, Cheney AK, Janda DH. Prevention of commotio cordis in baseball: an evaluation of chest protectors. J Trauma. 2000;49(6):1023–8.

    CAS  PubMed  Google Scholar 

  41. Link MS, Maron BJ, Wang PJ, Pandian NG, VanderBrink BA, Estes NA 3rd. Reduced risk of sudden death from chest wall blows (commotio cordis) with safety baseballs. Pediatrics. 2002;109(5):873–7.

    PubMed  Google Scholar 

  42. Drezner JA, Rogers KJ. Sudden cardiac arrest in intercollegiate athletes: detailed analysis and outcomes of resuscitation in nine cases. Heart Rhythm. 2006;3(7):755–9.

    PubMed  Google Scholar 

  43. Friedman FD, Dowler K, Link MS. A public access defibrillation programme in non-inpatient hospital areas. Resuscitation. 2006;69(3):407–11.

    PubMed  Google Scholar 

  44. Link MS, Maron BJ, Stickney RE, Vanderbrink BA, Zhu W, Pandian NG, et al. Automated external defibrillator arrhythmia detection in a model of cardiac arrest due to commotio cordis. J Cardiovasc Electrophysiol. 2003;14(1):83–7.

    PubMed  Google Scholar 

  45. Marenco JP, Wang PJ, Link MS, Homoud MK, Estes NA 3rd. Improving survival from sudden cardiac arrest: the role of the automated external defibrillator. JAMA. 2001;285(9):1193–200.

    CAS  PubMed  Google Scholar 

  46. 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(6):863–6.

    PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Medicals Department, Diakonhjemmet Hospital, Oslo, Norway

    Erik Ekker Solberg

  2. Department of Medicine, Division of Cardiology, UTSouthwestern Medical Center, Dallas, TX, USA

    Mark S. Link

Authors
  1. Erik Ekker Solberg
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Mark S. Link
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Mark S. Link .

Editor information

Editors and Affiliations

  1. Private Center for Sports and Exercise Cardiology, München, Bayern, Germany

    Axel Pressler

  2. University Institute of Sports Medicine Prevention and Rehabilitation, Paracelsus Medical University Salzburg, Salzburg, Austria

    Josef Niebauer

Review

Review

1.1 Questions

  1. 1.

    Which factors protect against commotio cordis?

  2. 2.

    What part of the cardiac cycle is most prone to cardiac arrest as a consequence of a blow to the chest?

  3. 3.

    Does a brisk alteration of the autonomic system play a role in inducing commotio cordis?

1.2 Answers

  1. 1.

    Protection is potentially achievable by three means: avoidance of chest blows, at least on the cardiac silhouette, chest wall protection e.g. by wearing specially designed gear, or using softer balls.

  2. 2.

    10–30 ms prior to the peak of the T-wave in ECG.

  3. 3.

    No, when double blocking the autonomic system no differences were found in eliciting SCA by a blow.

Rights and permissions

Reprints and permissions

Copyright information

© 2020 Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Solberg, E.E., Link, M.S. (2020). Commotio Cordis. In: Pressler, A., Niebauer, J. (eds) Textbook of Sports and Exercise Cardiology. Springer, Cham. https://doi.org/10.1007/978-3-030-35374-2_26

Download citation

  • DOI: https://doi.org/10.1007/978-3-030-35374-2_26

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-35373-5

  • Online ISBN: 978-3-030-35374-2

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation