Commotio cordis: Another cardiac arrest "sine materia". The 1707 early report and interpretation by G.M. Lancisi.

Sudden death by commotio cordis is rare. It is the consequence of a blunt trauma of the chest overlying the heart. The mechanism is a cardiac arrest by ventricular fibrillation in the absence of grossly or microscopically apparent myocardial injury. It has been reproduced in animals. The first historical case was reported by Giovanni Maria Lancisi in his book "De Subitaneis Mortibus'' published in 1707. Sudden death occurred in a man receiving a powerful blow under the xiphoid cartilage. Lancisi advanced the hypothesis of acute heart failure by a diastolic stand still ("death in diastole'').

Commotio cordis in non-sports-related injury: A scoping review.

Commotio cordis is a rare but life-threatening condition characterized by sudden cardiac arrest resulting from a blunt chest impact. While commotio cordis has traditionally been associated with sports-related activities, a significant proportion of cases occur in non-sport-related settings, such as assaults, motor vehicle accidents (MVAs), and daily activities. This critical review examines the epidemiology, clinical characteristics, and outcomes of non-sports-related commotio cordis cases, highlighting the need for increased awareness and improved management in these contexts. The review analyzes existing literature, drawing attention to the demographics of non-sports-related cases, which predominantly affect adolescents and young adults, with males being the primary demographic. In contrast to sport-related cases, non-sports-related commotio cordis cases exhibit a wider age range and a higher proportion of female subjects. Mortality rates are significantly higher in non-sports-related commotio cordis cases, largely due to lower rates of cardiopulmonary resuscitation (CPR), limited access to automated external defibrillators (AEDs), and delayed initiation of resuscitative efforts compared to sport-related incidents. This underscores the critical importance of increasing awareness and preparedness in non-sport-related settings. To mitigate the risks associated with non-sports-related commotio cordis, efforts should focus on early recognition of the condition, timely administration of CPR, and the widespread availability and accessibility of AEDs in various environments. Enhanced awareness and education can potentially lead to a reduction in mortality and improved outcomes for individuals affected by commotio cordis outside of sports-related activities. In conclusion, commotio cordis is not exclusive to sports and presents a significant health risk in non-sport-related scenarios. This review emphasizes the urgent need for increased awareness, preparedness, and resuscitation measures in non-sports contexts to address the higher mortality associated with these cases.

Commotio Cordis Returns When We Least Expected It: Cardiac Arrest in A Professional Football Player.

For the first time in 52 years, an American professional football player (Damar Hamlin) collapsed in cardiac arrest during a game, viewed in real-time on national television. The cause of this profound event was commotio cordis, that is, blunt non-penetrating chest blow-initiated ventricular fibrillation triggered by physical contact not considered unusual for football. The athlete survived because of timely cardiopulmonary resuscitation and defibrillation provided by first responders organized by the National Football League. Commotio cordis, albeit rare, was most prominently identified initially in competitive and also recreational sports participants. More recently it became apparent that similar events could occur in almost any circumstance involving a chest blow, such as during everyday activities around the home and with innocent play. The determinant of a commotio cordis event is a blow over the heart in a narrow vulnerable electrical window during dispersion of repolarization. Survival from these events has increased substantially to >60% due to enhanced recognition and prompt resuscitation/defibrillation. In conclusion, in this commentary, we take a timely opportunity to describe in detail the relevant demographics, mechanism/pathophysiology, and clinical course of commotio cordis.

Commotio Cordis in 2023.

Since the nationally televised cardiac arrest of American National Football League player Damar Hamlin in January 2023, commotio cordis has come to the forefront of public attention. Commotio cordis is defined as sudden cardiac arrest due to direct trauma to the precordium resulting in ventricular fibrillation or ventricular tachycardia. While the precise incidence of commotio cordis is not known due to a lack of standardized, mandated reporting, it is the third most common cause of sudden cardiac death in young athletes, with more than 75% of cases occurring during organized and recreational sporting events. Given that survival is closely tied to how quickly victims receive cardiopulmonary resuscitation and defibrillation, it is crucial to raise awareness of commotio cordis so that athletic trainers, coaches, team physicians, and emergency medical personnel can rapidly diagnose and treat this often-fatal condition. Broader distribution of automated external defibrillators in sporting facilities as well as increased presence of medical personnel during sporting events would also likely lead to higher survival rates.

Ventricular fibrillation arrest after blunt chest trauma in a 33-year-old man, commotio cordis?

BACKGROUND: Commotio cordis is an event in which a blunt, non-penetrating blow to the chest occurs, triggering a life-threatening arrhythmia and often sudden death. This phenomenon is often seen in young, male athletes and has become increasingly well-known over the past few decades. We present a unique case in which ventricular fibrillation occurs in an older male athlete after blunt trauma. CASE PRESENTATION: Patient with no known medical history was brought to the ER after being found unconscious after a soccer ball kick to the chest. He was found to be in ventricular fibrillation and successfully resuscitated on the soccer field. Patient was admitted to the hospital and lab workup and initial imaging were unremarkable, except elevated troponin and lactate, which returned to normal levels. An echocardiogram showed global left ventricular systolic dysfunction with a visually estimated ejection fraction of 45-50%. Coronary showed angiographically nonobstructive coronary arteries. The patient was diagnosed with commotio cordis and discharged from the hospital in stable condition. Follow-up echocardiogram continued to show low ejection fraction and event monitor demonstrated frequent polymorphic ventricular tachycardia with periods of asystole. CONCLUSION: This case is unique in that blunt trauma to the chest from a soccer ball immediately triggered ventricular fibrillation in a patient with a possible cardiomyopathy. It is possible that the blunt trauma caused primary commotio cordis that led to cardiomyopathy in a previous healthy man, or that an underlying cardiomyopathy made it more likely for this to occur. Overall, increased awareness and prevention efforts of blunt chest trauma are required to reduce the high mortality associated life-threatening arrhythmias. There is limited data regarding the interplay between these two entities.

Commotio cordis: A case report of a fatal blow.

Commotio cordis secondary to a blunt blow to the chest wall can result in ventricular fibrillation and sudden death in children. While it is commonly reported in adolescents during sporting activities, it may result from non-accidental trauma especially in infants and younger children. We report a case of a 6-month-old baby boy who presented to the emergency department in cardiac arrest. The patient's hospital records, postmortem imaging, and the autopsy results were reviewed. External examination of the infant did not reveal any evidence of trauma. Postmortem imaging revealed multiple healing posterior rib fractures and a metaphyseal corner fracture, both considered fractures highly specific for physical abuse. The autopsy revealed a structurally normal heart with no microscopic abnormalities. The infant's father confessed to hitting the child on the chest after which the child became unresponsive. Given the constellation of postmortem imaging and autopsy findings in addition to the father's confession, the child's death was ruled as a homicide secondary to commotio cordis. Since there are no structural and microscopic abnormalities in the heart autopsy in cases of commotio cordis, timely on-scene investigation and a thorough investigation regarding the mechanism of injury are required to make this diagnosis. Early identification of non-accidental trauma is crucial and can prevent further abuse in other siblings.

Don't Forget Commotio Cordis.

Non-penetrating chest blows can occasionally trigger fatal ventricular tachyarrhythmias and sudden death (commotio cordis). Such events were initially reported in association with sporting activities and projectiles such as baseball/lacrosse balls. However, similar potentially fatal chest blows, seemingly incapable of causing death, can occur during a variety of other circumstances such as when delivered during a fight (by a fist) such as in the accompanying paper. Notably, commotio cordis events can be reversed by resuscitation and defibrillation.

Commotio Cordis Resulting from Sibling Rivalry.

A 17-year-old girl with no significant medical, surgical, or family history presented to the emergency department following an episode of sudden cardiac arrest after being punched in the chest by her brother. Bystander CPR was immediately initiated, and she was found to be in ventricular fibrillation by emergency services. The patient had return of spontaneous circulation after one defibrillation event. No other significant injuries were found, and she eventually experienced a complete neurologic recovery and was discharged with no other identified cause for her arrest. The objective of this clinical case report is to highlight this unusual and rare injury to increase awareness and avoid incorrect diagnosis.

Atrial Fibrillation Induced From Commotio Cordis.

CASE: A 20-year-old male collegiate basketball player was evaluated for sudden chest pain, shortness of breath, dizziness, and blurry vision, following an elbow to the anterior chest by another player. His symptoms improved over 10 minutes of observation, but rhythm strip performed onsite showed atrial fibrillation, and the athlete was transmitted to the emergency department for further evaluation. Electrocardiogram in the ER confirmed atrial fibrillation with a rate of 85 bpm. Electrocardioversion was being arranged when he spontaneously converted to normal sinus rhythm, 2.5 hours from the traumatic event. CONCLUSIONS: Our case illustrates an unusual example of atrial fibrillation induced by commotio cordis (AFCC). Although less acutely life threatening and much less frequently described than ventricular fibrillation induced by commotio cordis, AFCC should be considered in the differential after blunt chest wall trauma. Currently, there are little data regarding management of patients with AFCC.

A Lethal Blow to the Chest as an Underdiagnosed Cause of Sudden Death in United Kingdom Sports (Football, Cricket, Rugby).

Nonpenetrating blunt force trauma to the front of the chest can lead to commotio cordis, a cardiac rhythm disturbance, which can result in cardiac arrest and death. The condition is particularly noted during sport. No series of such cases has been published in the UK. This study is a retrospective analysis of a database of 6000 cases of sudden cardiac death examining commotio cordis in the setting of collapse and death shortly following a blow to the precordium where no structural heart disease was identified at autopsy. Of the 17 cases, 16 were male, and 11 were 18 years old or younger. Eleven occurred whilst playing sport while 6 involved physical interaction including assault. The most common circumstance of death involved a youth being struck in the chest by a ball during sporting activity. In conclusion, this study demonstrates that cases of commotio cordis in the UK follow a similar circumstantial and age profile to those reported in the United States, and indicates that ball sports such as football, cricket, and rugby expose young participants to a similar risk. There is currently no nation-wide registry of deaths occurring during sporting activity in the UK, and although the true incidence of this condition is not currently known, it is most probably under-recognised and underdiagnosed.

Commotio cordis and L-type calcium channel mutation: Is there a link?

Commotio cordis is a rare phenomenon when ventricular fibrillation and sudden death occurs with a blunt, nonpenetrating blow to the chest. Individual susceptibility to commotio cordis has been demonstrated in swine models, and might be present in humans as well. We report a case of commotio cordis in an adolescent with a heterozygous mutation on the gene CACNA1C, encoding for an L-type calcium channel expressed in the heart. This genetic mutation has been previously associated with a phenotype of long-QT syndrome; however, this was not demonstrated in our patient despite extensive investigations. To the best of our knowledge, this is the first report of commotio cordis in which an ion-channel gene mutation involved in repolarization abnormalities has been documented. This finding might corroborate the hypothesis that a genetic predisposition plays a role in the individual susceptibility to this rare cause of cardiac arrest.

The role of the autopsy in the diagnosis of commotio cordis lethal cases: Review of the literature.

Commotio Cordis (CC) diagnosis is based on the occurrence of a blunt, non-penetrating blow to the chest preceding cardiovascular collapse and the absence of structural damage that would explain any observed effects. In CC lethal cases, the execution of the autopsy represents a possible diagnostic tool. Nevertheless, to date in the literature no author expresses an opinion about the use of the autopsy. In the light of the above, the authors propose a review of the literature about this topic. The review consents to state that the occurrence of a blunt blow to the chest is a necessary element for a lethal CC diagnosis, but it cannot be considered enough. Indeed, because CC is a recognized cause of sudden cardiac death, the autopsy should be always performed to exclude the presence of structural damage that would explain any observed effects. This approach is fundamental in order to achieve an accurate diagnosis and to distinguish CC from other causes of sudden cardiac death. In addition, the authors sustain that in case of autopsy data's lack the authors should not identify CC diagnosis as definitive but as possible.

Diagnostic Criteria for Commotio Cordis Caused by Violent Attack: Review of the Literature.

The diagnosis of lethal commotio cordis (CC) is really complex. The forensic pathologist's task is even more relevant when he/she has to explain a CC diagnosis caused by an assault in a trial. The purpose of this study was to analyze the literature on lethal CC as a result of violent attacks and identify relevant parameters that may help in the diagnosis. A review of the relevant articles was performed. Fifty-two cases of CC caused by violent attacks were identified. The collected data allowed to confirm the following literature's criteria for CC diagnosis in case of assaults: witnessed occurrence of a blunt, nonpenetrating blow to the chest preceding cardiovascular collapse; absence of structural damage to the sternum, ribs, or heart itself; and absence of any underlying cardiovascular abnormalities (such as other causes of sudden death). Regarding the assessment of the third criterion, the authors suggest that the pathologist should always specify the scientific autopsy guidelines that he/she used to differentiate CC from the other causes of sudden death. In addition, the authors highlight the importance of a multidisciplinary approach for a correct interpretation of clinical, autopsy, and laboratory findings.

Size as an Important Determinant of Chest Blow-induced Commotio Cordis.

PURPOSE: Commotio cordis is sudden cardiac death caused by a relatively innocent blow to the left chest wall. Adolescents account for the majority of the cases; whether this is due to the higher frequency of adolescents playing ball sports or whether there is some maturational reduction of risk is not known. METHODS: In a swine model of commotio cordis, the effect of body weight/size (directly related to age) to the susceptibility of chest impact-induced ventricular fibrillation (VF) is examined. METHODS: Ball impacts were delivered at escalating velocities from 48.3 to 96.9 km·h (30-60 mph) to 128 swine ranging in weight from 5 to 54 kg. RESULTS: VF occurred in 29% of impacts to the smallest animals compared with 34% in the 14- to 239-kg group, 27% in the 24- to 33.9-kg group, 30% in 34- to 43-kg group, and 15% in the 44- to 54-kg animals. The highest-weight group was associated with a significantly lower incidence of VF compared with other weights (P = 0.002). In a multivariate logistic regression analysis, controlling for repeated measures, four variables predicted VF: body weight (P = 0.0008), velocity (P < 0.0001), distance from the center of the heart, (P < 0.0001), and peak left ventricular pressure induced by the blow (P = 0.0007). CONCLUSIONS: In this experimental model, animals weighing <44 kg seem to have a similar susceptibility to commotio cordis, whereas animals weighing ≥44 kg have a lower susceptibility. An increase in size of the individual, rather than reduced play of ball sports, is the likely reason for the decreased commotio cordis incidence in older individuals.

Commotio cordis: A review.

Commotio cordis is an increasingly reported fatal mechano-electric syndrome and is the second most common cause of sudden cardiac death in young athletes. It is most commonly associated with a sports-related injury, wherein, there is a high-velocity impact between a projectile and the precordium. By virtue of this impact, malignant arrhythmias consequently develop leading to the individual's immediate demise, accompanied by a relatively normal post-mortem analysis. The importance of an autopsy remains paramount to exclude other causes of sudden death. With increasing awareness and reporting, survival rates are beginning to improve; however, prevention of the development of this condition remains the best approach for survival.

Homicidal commotio cordis caused by domestic violence: A report of two cases.

Commotio cordis is a rare and fatal mechano-electric arrhythmogenic syndrome, occurring mainly during sports activities. The present study describes two cases of sudden death due to homicidal commotio cordis caused violence from an intimate partner. The two decedents were both young women. They suffered from physical abuse by their intimate partner and collapsed immediately after being punched in the precordium. Electrocardiograms were recorded at the hospital and showed ventricular fibrillation in one case. An autopsy was performed in each case, and no structural cardiac damage, evident lesions of other internal organs or underlying diseases were found. Combined with the negative toxicological analysis, it was concluded that the cause of death was commotio cordis due to a blunt force to the anterior chest. To the best of the authors' knowledge, there is no published report on commotio cordis caused by physical abuse from an intimate partner. The accurate diagnosis of the cause of death is emphasised, as it is important for judicial fairness.

Atrial fibrillation induced by commotio cordis secondary to a blunt chest trauma in a teenage boy.

Low-energy blunt chest trauma can cause commotio cordis and ventricular fibrillation (VF) in otherwise healthy young individuals. If the chest wall impact occurs during a narrow vulnerable window of ventricular repolarization, the generated premature ventricular impulse can lead to VF and sudden death. Atrial fibrillation (AF) in association with a blunt chest trauma has not yet been reported in a child or adolescent. Our case describes a healthy 16-year-old boy who suffered blunt chest trauma during football practice. He was found to have AF, which resolved in 3 days without any therapy. He did not have any identifiable structural or electrical cardiac abnormality and had no previous history of arrhythmia. We hypothesize that AF, similar to commotio cordis-induced VF, may occur as a result of a blunt chest trauma in healthy young individuals. Animal studies evaluating arrhythmias related to chest wall impact may elucidate the timing and mechanism of AF induced by commotio cordis.