ne an d j of m e d

T he

w engl o u r n al ic i n e

r a
Medical Progress

eview rticle

Commotio Cordis
Barry J. Maron, M.D., and N.A. Mark Estes III, M.D.

entricular !i"rillation and sudden deat# triggered "y a "lunt, non$enetrating, and o!ten innocent%a$$earing unintentional "low to t#e c#est wit#out damage to t#e ri"s, sternum, or #eart &and in t#e a"sence o! underlying cardiovascular disease' constitute an event known as commotio cordis, w#ic# translates !rom t#e (atin as agitation o! t#e #eart. )#is term was ! irst used in t#e *+t# century,*%, alt#oug# t#e occurrence o! commotio cordis was descri"ed earlier, in accounts o! t#e ancient C#inese martial art o! Dim Mak &or touc# o! deat#', in w#ic# "lows to t#e le!t o! t#e sternum caused sudden deat# in o$$onents.- An a"sence o! structural cardiac injury distinguis#es commotio cordis !rom cardiac contusion, in w#ic# #ig#%im$act "lows result in traumatic damage to myocardial tissue and t#e overlying t#ora.. Beginning in t#e mid%*-//s, s$oradic accounts o! commotio cordis a$$eared in t#e medical literature, mostly in t#e conte.t o! work$lace accidents,0%*/ and t#roug# t#e mid%*++/s, t#e disorder was noted only occasionally in case re$orts, going largely unrecogni1ed, e.ce$t

"y t#e !orensic $at#ology community and t#e Con% sumer 2roduct 3a!ety Commission.,,**%*4 3ince * t#en, #owever, "ot# t#e general $u"lic and t#e medical community #ave "ecome increasingly aware o! commotio cordis as an im$ortant cause o! sudden cardiac deat#. It occurs $rimarily in c#il% dren, adolescents, and young adults, most o!ten during $artici$ation in certain recreational or com$etitive s$orts, wit# rare occurrences during

)#e New England Journal o! Medicine Downloaded !rom nejm.org on Marc# 5, 6/*4. 7or $ersonal use only. No ot#er uses wit#out $ermission. Co$yrig#t 8 6/*/ Massac#usetts Medical 3ociety. All rig#ts reserved.

normal, routine daily activities.*,6,,,*5%*+ Continued interest in commotio cordis and its tragic conse9uences is evident in e$idemiologic studies*,6,*+ and a num"er o! e.$erimental la"oratory investiga% tions.6/%:5 )#is review !ocuses on t#e availa"le in!ormation regarding t#e clinical $ro!ile, $ro$osed mec#anisms, and $revention and treatment o! commotio cordis. In c id e n ce )#e $recise incidence o! commotio cordis is unknown "ecause o! t#e a"sence o! systematic and mandatory re$orting, "ut on t#e "asis o! data !rom t#e National Commotio Cordis ;egistry in Minnea$olis,*,6,*it is among t#e most !re9uent car% diovascular causes o! sudden deat# in young at#letes, a!ter #y$ertro$#ic cardio% myo$at#y and congenital coronary%artery anomalies.*-,*0 3ince commotio cordis occurs in a wide variety o! circumstances, it #as undou"tedly "een underre$orted "ut it is "eing recogni1ed wit# increasing !re9uency and is $ro"a"ly more common t#an it is "elieved to "e.

7rom t#e <y$ertro$#ic Cardiomyo$at#y Center Minnea$olis <eart Institute 7oun% dation, Minnea$olis &B.J.M.'= and t#e New England Cardiac Arr#yt#mia Center, Cardiology Division, )u!ts >niversity 3c#ool o! Medicine, Boston &N.A.M.E.'. Address re$rint re9uests to Dr. Maron at Minnea$olis <eart Institute 7oundation, +6/ E. 60t# 3t., 3uite ,6/, Minnea$olis, MN 554/-, or at #cm.maron?m#i!.org. N Engl J Med 6/*/=:,6@+*-%6-. Copyright 2010 Massachusetts Medical Society.

E $i de m iol o g y
In addition to e$isodic case studies,0,*6%*4,:,%44

most s$eci! ic in!ormation concern% ing t#e clinical $ro! ile o! commotio cordis comes !rom t#e Minnea$olis registry,
n engl j med :,6=*/ nejm.org marc# **, 6/*/

+*-

)#e New England Journal o! Medicine Downloaded !rom nejm.org on Marc# 5, 6/*4. 7or $ersonal use only. No ot#er uses wit#out $ermission. Co$yrig#t 8 6/*/ Massac#usetts Medical 3ociety. All rig#ts reserved.

T he

n e w e n g l an d j o u r n al

of m

e d ic i n e

A
-/ 3urvivors 3udden deat#s Com$etitive s$orts ;ecreational s$orts ;outine daily activities

No. of Commotio Cordis Events

,/ 5/ 4/ :/ 6/ */ / B*/ **C*5 *,C6/

6*C65

D6,

Age at Event (yr)

instantaneous, 6/F o! victims remain $#ysically active !or a !ew seconds a!ter t#e "low &e.g., continuing to walk, run, skate, t#row a "all, or even s$eak', w#ic# may re! lect individual toler% ance !or sustained ventricular tac#yarr#yt#mias. 7or e.am$le, a "ase"all $itc#er struck in t#e c#est "y a "atted "all was a"le to retrieve t#e "all at #is !eet, success!ully com$lete t#e $lay &t#rowing out t#e "ase runner', and t#en $re$are !or #is ne.t $itc# "e!ore colla$sing. In anot#er instance, a "at% ter was struck "y a $itc# w#ile attem$ting to "unt and colla$sed only a!ter running to !irst "ase.
Competitive Sports

B
Base"all 3o!t"all <ockey 7oot"all 3occer (acrosse Bo.ing Cricket ;ug"y Aarate Basket"all / 6/ 4/ ,/ 0/ ;ecreational s$orts &NE40' Com$etitive s$orts &NE* 66'

No. of Commotio Cordis Events

A"out 5/F o! commotio cordis events #ave "een re$orted in young com$etitive at#letes &mostly t#ose "etween ** and 6/ years o! age' $artici$at% ing in a variety o! organi1ed amateur s$orts G ty$ically "ase"all, so!t"all, ice #ockey, !oot"all, or lacrosse G w#o receive a "low to t#e c#est t#at is usually &"ut not always' delivered "y a $ro% jectile used to $lay t#e game. In "ase"all, !or e.% am$le, commotio cordis is o!ten triggered w#en $layers are struck in t#e c#est "y "alls t#at #ave "een $itc#ed, "atted, or t#rown in a variety o! scenarios &)a"le *, 7ig. 6'. In #ockey, de!ensive $layers may intentionally use t#eir c#ests to "lock t#e $uck !rom an o$$onentHs #ig#%velocity s#ot. <ig#%sc#ool and college lacrosse $layers &includ% ing goalies wit# c#est $rotectors' may "e at great%

Figure . !istri"ution of Commotio Cordis Events According to Age and Activity.

A>)<I;@ Maron 7IJ>;E@ * o! : A;)I3)@ M;(
;E)AAE@ *st

6nd ;evised :rd

S#$E

)K2E@ (ine

Com"o

4%C

<L)

2anel A s#ows t#e distri"ution o! commotio cordis events according to age and ty$e o! activity in 664 cases !rom t#e National Commotio Cordis ;egis% try recorded over t#e $ast *5 years.*,6,*+ 2anel

B s#ows t#e distri"ution o! suc# events according to t#e $articular s$ort.

" ee n re dr a. n Fig ur e - a s A%&'()* P+EASE N(&E, w # ic# # a s d o c umandentytpeed-as6"6e4encreasseet.s since its cre% ation *5Pyleeaasresc-aegc/oc.a*r,6ef,u*+lly&.7ig. *'. Commotio cordis JIB@ :,*.s.#ows a $redilection !or c#ilI3d3r>eEn@ a:%n**d% * / a dolescents &mean age, *5M+ years= range, , weeks to 5/ years'. According to t#e registry, 6,F o! victims were younger t#an */ years o! age, and only +F were

65 years o! age or older. )#e condition #as rarely "een re$orted in "lacks or in girls or women= most victims are "oys or men &+5F' and are w#ite &-0F'. Commotio cordis resulting !rom "lows to t#e c#est !rom $rojectiles &$redominantly "ase% "alls, so!t"alls, lacrosse "alls, or #ockey $ucks' or "lunt "odily contact wit# ot#er at#letes are most common in c#ildren younger t#an *5 years o! age. Alt#oug# cardiovascular colla$se is virtually

er risk !or commotio cordis t#an at#letes in ot#er s$orts t#at involve similarly solid $rojectiles &e.g., "ase"alls'.*+ Commotio cordis may also result !rom $#ysical contact "etween com$etitors. 3uc# c#est "lows are $roduced "y t#e s#oulder, !ore% arm, el"ow, leg, !oot, or #ead, as w#en two out% ! ielders inadvertently collide w#ile tracking a "ase"all in t#e air, or, alternatively, w#en a #ockey stick is t#rust into an o$$onentHs c#est. )ecreational Sports Anot#er 65F o! commotio cordis events occur in recreational s$orts $layed at #ome, on t#e $lay% ground, +* 0

or at $icnics or ot#er !amily gat#erings. )#ese innocent%a$$earing events occur wit# dis% $ro$ortionate !re9uency in t#e youngest known victims &*/ years old or younger', wit# close !am% ily mem"ers &e.g., $arents or si"lings' or !riends o!ten res$onsi"le !or t#e "low. In one e.am$le, a c#ild $laying catc# wit# a $arent misjudged t#e ! lig#t o! t#e "all, w#ic# was t#en de! lected o!! #is glove, striking #is c#est. In recreational s$orts,

n engl j med :,6=*/

nejm.org marc# **, 6/*/

Medic al 2rogr ess &a"le . E0amples of Circumstances in 1-ic- C-est Blo.s 'ave &riggered Commotio Cordis. Sports Base"all, so!t"all, cricket Batter struck "y a $itc#ed "all Batter #it "y $itc#ed "all w#ile attem$ting to "unt 2itc#er #it "y a "atted or t#rown "all Base runner #it "y a "atted or t#rown "all w#ile running or sliding 2layer inadvertently in $at# o! t#rown or "atted "all Catc#er, um$ire, s$ectator, or "ystander #it "y a !oul "all Batter on deck #it "y an errant t#row Catc#er struck "y a "at 7ielders or "ase runners involved in "odily collision 7ielder #it w#en !lig#t o! "all was misjudged and "all de!lected o!! glove 2layer !ell on so!t"all a!ter catc#ing it 2layer #it "y "owled cricket "all 7oot"all 2layer #it in "odily collision wit# o$$onentHs #elmet, !orearm, s#oulder, or knee, usually during "locking or tackling or a!ter $ass rece$tion 2layer struck "y "all w#ile "locking $unt 3occer 2layer collided wit# goal$ost Joalie struck "y s#ot on goal 2layer kicked in c#est "y o$$onent <ockey Joalie or ot#er de!ensive $layer struck "y s#ot on goal 2layer #it in "odily collision involving c#ecking 2layer struck "y sla$ s#ot G #ockey $uck traveling at #ig# s$eed 2layer struck "y #ockey stick (acrosse Joalie #it "y #ig#%velocity s#ot on goal 2layer #it "y "all $assed !rom teammate Fig-ts and scuffles* .it- "lo. from -and or el"o. 2syc#iatric aide struck "y $atient )eac#er struck w#ile restraining student during !ig#t Kout# struck during $lay G s#adow"o.ing or roug##ousing Kout# struck "y "o.ing glove during s$arring C#ild struck "y $arent or "a"ysitter &wit# disci$linary intent' Koung adult struck

during slam dancing 3tudent involved in !ist !ig#t at !raternity $arty Kout# #it "y snow"all Adult struck in $rison gang initiation ritual In!ant struck wit# o$en #and w#ile #aving dia$er c#anged (t-er circumstances C#ild kicked "y #orse Kout# #it wit# recoil o! gun "utt w#ile deer #unting C#ild #it wit# re"ound o! $layground swing Adult t#rown against steering w#eel during automo"ile accident Kout# #it "y tennis "all !illed wit# coins Koung adult kicked during c#eerleading routine Adult received c#est "low "y !alling into "ody o! water C#ild received "low !rom #ead o! 6:%kg &5/%l"' $et dog C#ild received "low !rom !alling on $layground a$$aratus C#ild #it "y tossed #ollow $lastic "at C#ild #it "y $lastic sledding saucer Kout# received "low intended to terminate #iccu$s C#ild #it #andle"ars w#ile !alling o!! "icycle n engl j med :,6=*/
+*+

nejm.org marc# **, 6/*/

T he n e w e n g l an d j o u r n al of m e d ic i n e t#e s$eed o! t#e $rojectiles causing c#est "lows ranges widely, !rom t#e low% velocity "alls t#rown during in!ormal games o! catc# to #ig#%velocity lacrosse or cricket "alls. (t-er Activities Commotio cordis is unrelated to s$orts activities in a"out 65F o! victims &most o!ten t#e young% est' &7ig. *'. )#ese incidents occur in a wide vari% ety o! circumstances, suc# as "eing kicked in t#e c#est "y a #orse or struck "y a $layground swing as it re"ounds. In occasion, suc# accidents are "roug#t to court. C#arges o! murder or man% slaug#ter #ave led to criminal $rosecution and incarceration.45%4+ I u t c om e Commotio cordis is usually, alt#oug# not invari% a"ly, !atal.*,6,*+,5/,5* In only a"out 65F o! t#e cases re$orted in t#e Minnea$olis registry #as cardio$ulmonary resuscitation or de! i"rillation resulted in survival G a low $ercentage, consider% ing t#at commotio cordis is de! ined "y t#e a"% sence o! structural #eart disease. )#e outcome is related largely to t#e circumstances in w#ic# commotio cordis occurs. Deat#s #ave o!ten "een associated wit# t#e !ailure o! "ystanders to a$% $reciate t#e li!e%t#reatening nature o! t#e colla$se and to initiate a$$ro$riately aggressive and timely measures o! resuscitation.6,*;egistry data s#ow t#at survival rates #ave increased over time, rising to :5F over t#e $ast decade, as com$ared wit# *5F !or t#e $receding */ years &2 E /./*'= most recently G "etween 6//, and 6//+ G t#e num"er o! success!ul resuscita% tions e.ceeded t#e num"er o! deat#s "y 6/F. )#is im$rovement is $ro"a"ly t#e result o! in% creased $u"lic awareness, t#e increased availa"il% ity o! automatic e.ternal de! i"rillators &AEDs', and earlier activation o! t#e c#ain o! survival &call to +** and initiation o! cardio$ulmonary resuscitation, de! i"rillation, and advanced li!e% su$$ort measures'. Arr#yt#mias recorded at t#e time o! colla$se or in t#e emergency room are o!ten caused "y ventricular !i"rillation,6 suggest% ing t#at restoration o! sinus r#yt#m and survival are $ossi"le, given $rom$t de! i"rillation. 3ome commotio cordis events may a"ort s$on% taneously, w#en t#e "low causes nonsustained arr#yt#mias, alt#oug# t#is is di!! icult to con% ! irm. 3uc# cases #ave "een recorded in t#e reg%

istry, including t#e case o! a $ro!essional #ockey $layer w#o colla$sed immediately a!ter "eing struck in t#e c#est "y a $uck traveling at #ig# velocity. )#e $layerHs slow $ulse suggested tran% sient com$lete #eart "lock &or anot#er "radyar% r#yt#mia', as #as "een re$orted in la"oratory settings, in w#ic# a "low to t#e c#est is timed to occur during t#e N;3 com$le.6/= t#e $layer regained consciousness s$ontaneously, wit#in a !ew minutes a!ter #is colla$se, and recovered.56 M e c # a n is m s Commotio cordis is a $rimary arr#yt#mic event t#at occurs w#en t#e mec#anical energy gener% ated "y a "low is con! ined to a small area o! t#e $recordium and $ro!oundly alters t#e electrical sta"ility o! t#e myocardium, resulting in ventric% ular ! i"rillation. A variety o! "iologic and "iome% c#anical e.$erimental models o! commotio cordis #ave "een develo$ed to elucidate t#e mec#anisms "y w#ic# a ra$id mec#anical stimulus to t#e c#est triggers ventricular :,4,0,6/,65%6+,:4,:5,5:%55 !i"rillation. Early e!!orts, dating "ack to t#e late *+t# century, to re$licate commotio cordis in animals were relatively crude, making use o! #ammers and ot#er "lunt instruments t#at o!ten resulted in deat# !rom direct trauma.:,4,0,+ )#ese early inves% tigations yielded several t#eoretical e.$lanations !or t#e mec#anics o! t#e event, +6 /

including e.ces% sive autonomic &vagal' re! le.,,0,+ and coronary arterial vasos$asm,:,4,,,0 t#at #ave since "een a"andoned. During testing in later models, "ase% "alls were $ro$elled at s$eeds o! u$ to *5: km &+5 mi' $er #our, causing severe injuries to t#e t#ora. and #eart &cardiac contusion' "ut not commotio cordis.5: !eterminants and &riggers More recent e.$erimental la"oratory studies con% ducted under controlled conditions in $igs, dogs, and ra""its6/% 6-,6+%:5,5: #ave $rovided insig#ts into t#e underlying mec#anisms o! commotio cordis t#at are consistent wit# its clinical $ro! ile and #ave dis$elled t#e notion t#at sudden deat# a!ter a "low to t#e c#est is a mysterious $#enome% non.*,6 Ine model, in w#ic# $rojectile% induced "lows were delivered at a wide range o! velocities to anest#eti1ed young $igs in sync#roni1ation wit# t#e cardiac cycle, revealed two critically im% $ortant mec#anical determinants o! ventricular ! i"rillation and let#ality &7ig. 6'.6/,:: nejm.org marc# **, 6/*/

n engl j med :,6=*/

Medic al 2rogr ess

Figure 2. Pat-op-ysiology of Commotio Cordis. In recreational and com$etitive s$orts, c#est "lows may involve "alls or $ucks or may "e in! licted t#roug# "odily contact. )#e location o! t#e "low on t#e c#est and its timing relative to t#e cardiac cycle are t#e $rimary determi% nants o! commotio cordis. It#er !actors t#at may contri"ute to t#e risk o! an event include t#e density, si1e, and orientation o! t#e $rojectile and t#e s#a$e o! t#e t#ora.= younger $eo$le are t#e most vulnera"le "ecause o! t#eir t#inner, less develo$ed ri" cage and musculature. )#e ! irst o! t#ese determinants involves t#e location o! t#e "low, w#ic# must "e directly over t#e #eart &$articularly at or near t#e center o! t#e cardiac sil#ouette'.6/,:: )#is !inding is consistent wit# clinical o"servations t#at $recordial "ruises re$resenting t#e im$rint o! a "low are !re9uent% ly evident in victims.*,6 )#ere is no evidence in #umans or in e.$erimental models t#at "lows sustained outside t#e $recordium &e.g., t#e "ack, t#e ! lank, or t#e rig#t side o! t#e c#est' cause sudden deat#.6-,:: )#e second determinant concerns t#e timing o! t#e "low, w#ic# must occur wit#in a narrow window o! */ to 6/ msec on t#e u$stroke o! t#e ) wave, just "e!ore its $eak &accounting !or only *F o! t#e cardiac cycle' G t#at is, t#e "low must occur during an electrically vulnera"le $eriod,

w#en in#omogeneous dis$ersion o! re$olari1a% tion is greatest, creating a susce$ti"le myocardial su"strate !or $rovoked ventricular ! i"rillation &7ig. 6'.6/ In $igs, w#en "lows occurred outside t#is "rie! window o! time, ventricular !i"rillation was not t#e conse9uence= instead, w#at !ollowed was transient com$lete #eart "lock, le!t "undle% "ranc#

"lock, or 3)%segment elevation.6/ )#ese e!!ects #ave also "een re$orted in some #uman survivors &wit# t#e $resumed timing o! t#e "low coinciding wit# t#e N;3 com$le. during ventric% ular de$olari1ation'.*6,5/ )#e energy o! t#e im$act associated wit# com% motio cordis is not uni!orm, c#aracteristically encom$assing a wide range o! velocities as well as $rojectile si1es, s#a$es, and weig#ts. 2rojec% tiles include #ockey $ucks and lacrosse "alls

n engl j med :,6=*/

+6*

nejm.org marc# **, 6/*/

T he n e w e n g l an d j o u r n al of m e d ic i n e $ro$elled at s$eeds o! u$ to *45 km &+/ mi' $er #our,*,6 as well as seemingly innocuous o"jects, suc# as $lastic toy "ats and sledding saucers, t#at can "ecome let#al w#en striking small c#il% dren, even at slow s$eeds. >nder e.$erimental conditions, t#e likeli#ood t#at ventricular ! i"ril% lation will "e triggered "y a $rojectile t#e si1e o! a "ase"all increases $rogressively u$ to an im$act velocity o! ,4 km &4/ mi' $er #our, a s$eed ty$ically delivered "y **% and *6%year%old $itc#% ers.64 At #ig#er velocities &e.ceeding 0/ km O5/ miP $er #our', t#ere is an increased risk o! structural damage to t#e c#est and #eart, including myo% cardial "ruising and ru$ture t#at are c#aracter% istic o! cardiac contusion &rat#er t#an commotio cordis'.64,5: It#er !actors t#at may increase t#e risk o! ventricular ! i"rillation and commotio cordis in% clude t#e #ardness o! t#e o"ject and its si1e and s#a$e, wit# #ard, small, s$#ere%s#a$ed $rojec% tiles most likely to do #arm.6/,6:,5, )#e $redis$o% sition to commotio cordis in young $eo$le may largely "e related to $#ysical c#aracteristics o! t#e t#ora. in t#e young::,5,= t#e relatively t#in, underdevelo$ed, com$liant c#est cage &and im% mature intercostal musculature' is less ca$a"le o! "lunting t#e arr#yt#mogenic conse9uences o! $recordial "lows.*,6 In addition, since c#ildren $ro"a"ly incur c#est "lows more !re9uently t#an adults in a variety o! circumstances, t#ey may generally "e at greater risk !or commotio cordis. Adults $ro"a"ly gain a measure o! $rotection !rom t#eir mature and !ully develo$ed c#est cage, w#ic# may e.$lain in $art t#e a$$arently low rate o! commotio cordis events in s$orts suc# as kick"o.ing and "o.ing &accounting !or less t#an 5F o! registry cases'. In "o.ing, it is also $os% si"le t#at t#e glove itsel!, w#ic# increases t#e area o! im$act, #el$s to "u!!er t#e !orce o! t#e "low.6 )#e 9uestion o! w#et#er susce$ti"ility to com% motio cordis varies "ecause o! individual varia% tions in t#e lengt# o! t#e N) interval #as "een considered "ut remains unanswered. )#ere is no evidence t#at survivors o! commotio cordis are at increased risk !or su"se9uent arr#yt#mic events, nor is t#ere evidence t#at at#letes w#o #ave #ad a commotio cordis event s#ould "e dis9uali! ied !rom com$etition solely !or t#at reason. 3imilarly, $ro$#ylactic im$lanta"le de! i"rillators are not indicated !or $ersons w#o #ave survived com% motio cordis in t#e a"sence o! cardiac disease.

Cellular Mec-anisms )#e cellular &and su"cellular' mec#anisms res$on% si"le !or commotio cordis a$$ear to "e multi!ac% torial and com$le., and t#ey remain incom$letely de! ined. In!ormation o"tained !rom e.$eriments wit# (angendor!! $re$arations o! $er!used ra""it #eart6- and !rom animal models6*,64,:/%:6 #as led to #y$ot#eses concerning s$eci! ic mec#anistic $at#ways. It is "elieved t#at t#e mec#anical !orce generated "y $recordial "lows during re$olari1a% tion causes le!t ventricular intracavitary $ressure to rise instantaneously to 65/ to 45/ mm <g= t#is rise in $ressure is directly correlated wit# an increased $ro"a"ility o! ventricular ! i"rilla% tion.6*,64,6-,:: It #as "een #y$ot#esi1ed t#at t#is elevation in $ressure causes cell mem"ranes to stretc#, activating ion c#annels and increasing transmem"rane current ! low "y means o! me% c#anicalCelectric cou$ling.6*,6,,6-,6+,:/,:5 )#e resul% tant am$li! ied dis$ersion o! re$olari1ation cre% ates an in#omogeneous and electrically vulnera"le su"strate t#at is susce$ti"le to ventricular ! i"ril% lation. )#e candidate ion c#annels include t#e A)2%sensitive $otassium c#annel,6, w#ic# contri"% utes to t#e initiation o! ventricular ! i"rillation in commotio cordis6* and in myocardial in!arction and isc#emia.5-%,6 It is $ossi"le t#at t#e mec#a% nism "y w#ic# ventricular ! i"rillation occurs in commotio cordis, wit# ventricular de$olari1ation induced "y a "low to t#e c#est, #as somet#ing in common wit# t#e $at#o$#ysiological +6 6

mec#anisms t#at give rise to $rimary arr#yt#mogenic condi% tions, suc# as ion c#annelo$at#ies.,:%,0
2r e v en t i v e 3 t r a t e g i s C o n s i d er a t a n d 7 u t u ree

ions

Primary Prevention )#e risk o! commotio cordis is associated wit# li!estyle and t#ere!ore can "e modi! ied. Ine means o! $revention is $u"lic education G $eo% $le s#ould "e made aware o! t#e im$ortance o! avoiding $recordial "lows.5, It is $articularly im% $ortant to increase awareness t#at even an unin% tentional, modest%seeming "low to t#e c#est de% livered wit#out malice &e.g., in $lay!ul "o.ing' can trigger li!e% t#reatening ventricular tac#yarr#yt#% mias.6 Even so, since t#ere are so many circum% stances in w#ic# commotio cordis can occur &)a"le *', elimination o! t#ese events is an unre% alistic goal. Irgani1ed s$orts $resent t#e greatest o$$or%

n engl j med :,6=*/

nejm.org marc# **, 6/*/

Medic al 2rogr ess tunity to $revent commotio cordis. 7or e.am% $le, t#e risk would $ro"a"ly "e reduced "y means o! im$roved coac#ing tec#ni9ues, suc# as teac#% ing ine.$erienced young "atters in "ase"all and so!t"all #ow to turn away !rom t#e "all to avoid errant $itc#es.5,,,+ De!ensive $layers in lacrosse and #ockey can "e coac#ed to avoid using t#eir c#est to "lock t#e "all or $uck w#en $rotecting t#eir goal. Coac#ing clinics s$onsored "y t#e National Collegiate At#letic Association now strongly discourage any tactic t#at $laces lacrosse $layers &w#o are not goalies' directly in t#e $at# o! s#ots on goal. Im$roved design o! commercial s$orts e9ui$% ment would also $ro"a"ly #el$ to $revent com% motio cordis. Ine e.am$le is t#e sa!ety "ase"all, a so!ter "all intended !or $layers younger t#an *: years o! age= t#e sa!ety "ase"all is made entirely o! ru""er, wit#out t#e dense, #ard core o! cork and twine !ound in standard "ase"alls. A direct relation "etween t#e #ardness o! t#e "all and t#e likeli#ood o! ventricular !i"rillation #as "een demonstrated in t#e la"oratory, and let#al ar% r#yt#mias occur less !re9uently w#en t#e "alls used #ave "een manu!actured !or reduced #ard% 6/,6:,5, ness. <owever, so!ter "alls will not "e ac% ce$ted i! t#ey c#ange t#e nature o! t#e game, and t#eir a"solute e!!ectiveness in reducing t#e risk o! commotio cordis #as not "een document% ed in t#e ! ield. In !act, so% called sa!ety "ase"alls #ave "een res$onsi"le !or several !atal events.6 )#e o"servation t#at t#e air%! illed "alls used in soccer, tennis, and "asket"all are rarely im$li% cated in commotio cordis &accounting !or only 4F o! $rojectile%related deat#s, according to t#e Minnea$olis registry' is consistent wit# t#e $rin% ci$le t#at solid $rojectiles are more likely to $reci$itate ventricular ! i"rillation= air%! illed "alls are $resumed to "e sa!er "ecause o! t#eir $ro% $ensity to colla$se, or give, on contact and to a"sor" some o! t#e energy o! t#e im$act. C#est $rotectors and vests #ave "een a !ocus !or $rimary $revention o! commotio cordis in certain s$orts.:4,54,5,,-/,-* <owever, registry data indicate t#at t#e most commonly used, commer% cially availa"le $rotectors, w#ic# were originally designed to reduce t#e likeli#ood o! trauma !rom "lunt "odily injury G "ut not to $rovide $rotec% tion against commotio cordis G do not o!!er a"solute $rotection !rom arr#yt#mia a!ter a "low to t#e c#est.*,6,*+,-/ Indeed, currently availa"le c#est $rotectors may create a !alse sense o! secu%

rity, given t#at almost 6/F o! t#e victims o! commotio cordis in com$etitive !oot"all, "ase% "all, lacrosse, and #ockey were wearing e9ui$% ment marketed as $roviding $rotection against traumatic c#est injury &7ig. :'.*,6,+,-/,-6 In several !atal cases o! commotio cordis in lacrosse goal% ies, t#e "all struck t#e c#est $rotector directly.*+ 3uc# cases suggest t#at t#e material t#e $rotec% tors were made !rom was inade9uate. In ot#er cases o! commotio cordis, a ! lawed design o! t#e c#est "arrier allowed t#e $rojectile direct access to t#e $recordium. 7or e.am$le, in #ockey, w#en a $layerHs arms are !ully raised, t#e $rotector can migrate u$ward, e.$osing t#e c#est wall to a di% rect "low.*,-/,-6 Con! irmatory evidence !rom ani% mal models indicates t#at t#e commercially $ro% duced c#est $rotectors now $romoted !or use in "ase"all and lacrosse are ine!!ective in consis% tently $reventing ventricular ! i"rillation G t#at is, wearing suc# $rotectors does not reduce t#e risk o!

sudden deat#.65,:4 Develo$ment o! a c#est "arrier t#at is ade% 9uately designed to $revent commotio cordis dur% ing s$orts com$etition may $rove di!!icult. )o "e e!!ective, a c#est $rotector would #ave to a"sor" and dissi$ate t#e energy generated "y t#e $re% cordial im$act.5, In la"oratory studies, a mec#an% ical model t#at could di!!use t#e !orce o! c#est "lows over an increased sur!ace area was most e!!ective in $reventing commotio cordis.54 7ur% t#ermore, "ot# clinical o"servations*,6,*+ and la"% oratory data65,:4,-/ suggest t#at closed%cell !oam, w#ic# is t#e $rimary constituent o! most com% mercially availa"le c#est $rotectors, is easily $en% etrated "y $rojectiles and does not $rovide ade% 9uate $rotection against commotio cordis. It is likely t#at c#est $rotectors would "e more e!!ec% tive i! t#ey were made !rom #arder, more rigid, and more resistant materials and !rom !oams ca$a"le o! a"sor"ing and dis$ersing greater amounts o! energy. In $ractical design terms, suc# a c#est $rotector s#ould "e ada$ta"le !or use "y at#letes $laying any $osition in any s$ort in w#ic# t#ere is a risk o! commotio cordis= cur% rently, t#e use o! suc# $rotectors is largely lim% ited to goalies in lacrosse and #ockey and to catc#ers in "ase"all, $ositions t#at #ave "een associated wit# 6/F o! all commotio cordis events.-/ An ideal c#est%wall $rotector would also #ave to "e a!!orda"le, dura"le, and com$ati"le wit# t#e !ull range o! $#ysical activity and com% !ort re9uired "y at#letes in a given s$ort and nejm.org marc# **, 6/*/

n engl j med :,6=*/

+6:

T he n e w e n g l an d j o u r n al of m e d ic i n e
A B C

)otal cases 664

;ecreational s$orts or

++ ot#er circumstances Com$etitive s$orts

C#est $rotector

*65
No c#est $rotector 50 + Base"all or so!t"all 3occer

4/

05

(acrosse
* <ockey It#er s$orts */

*<ockey

*4 7oot"all

5 Base"all

4 (acrosse

Figure 3. Means of Protection from Commotio Cordis. Commercially availa"le c#est $rotectors #ave $roved inade9uate in t#e $revention o! sudden deat# due to commo% tio cordis. ;easons !or t#e inade9uacy include t#e !act t#at t#e $rotector may move w#en t#e arms are raised, leav% ing t#e $recordium e.$osed &as in t#e case o! t#e $rotector s#own in 2anel A, w#ic# is used in #ockey',*,-6 or

t#at t#e com$osite material t#e $rotector is made !rom does not ade9uately attenuate t#e "low &as in t#e case o! t#e $rotector s#own in 2anel B, w#ic# is used "y "ase"all catc#ers'.65 3o!ter "ase"alls &2anel C', made wit# ru""er cores rat#er t#an t#e standard%issue cork and twine, intended to avert commotio cordis events in c#ildren, #ave nonet#eless "een res$onsi"le !or suc# events. A ! low diagram &2anel D' "ased on data derived !rom t#e 664 !atal cases o! commotio cordis recorded in t#e National Commotio Cordis ;egistry s#ows t#at in com$etitive s$orts, almost one t#ird &4/ o! *65' o!
would #ave to meet $res$eci! ied $er!ormance standards.54

Secondary Prevention AEDs #ave su"stantial li!e%saving ca$a"ility, and it is a$$ro$riate to disseminate t#em widely at yout# s$orting events and recreational settings w#ere commotio cordis may occur.-: A $u"lic #ealt# strategy t#at incor$orates a $lan !or making AEDs widely availa"le is likely to result in t#e sur% vival o! more young $eo$le in t#e event o! com% motio cordis, as indicated "y current registry data and several cases in w#ic# an AED was e!!ective +6 4

in terminating li!e%t#reatening ventricular tac#y% arr#yt#mias and restoring sinus r#yt#m.6,,+,-4,-5 Indeed, AEDs #ave also e!!ectively terminated ventricular ! i"rillation in animal models o! commotio cordis.66 <owever, even under o$ti% mal conditions, an AED can !ail to restore t#e #eart to normal r#yt#m a!ter commotio cordis, as was t#e case wit# a college lacrosse $layer w#o was not a goalie "ut was struck in t#e c#est "y a "all and died, des$ite $articularly $rom$t e!!orts at resuscitation and de! i"rillation.-, Bot# clinical studies--%0* and e.$erimental studies06 suggest t#at $recordial t#um$s are unrelia"le in nejm.org marc# **, 6/*/

n engl j med :,6=*/

Medic al 2rogr ess terminating ventricular !i"rillation caused motio cordis events. 7urt#er e!!orts are "y c#est "lows. needed to $revent t#ese largely avoida"le deat#s "y $ro% viding more education, 3 um m a r y "etter%designed at#letic e9ui$ment &e.g., e!!ective c#est%wall $rotectors', and wider In t#e $ast decade, t#e general $u"lic and access to AEDs at organi1ed at#letic events. t#e medical community #ave "ecome more )#ese strategies s#ould result in a sa!er aware o! commotio cordis as an im$ortant s$orts environment !or our yout#. cause o! sud% den deat#. Commotio cordis occurs in ot#erwise #ealt#y and active 3u$$orted in $art "y grants !rom t#e young $eo$le, ty$ically during recreational <earst 7oundations, t#e (ouis J. Acom$ora and com$etitive s$orts "ut in some cases Memorial 7oundation, and t#e National I$% even during normal daily activities. A variety erating Committee on 3tandards !or At#letic o! e.$erimental models indicate t#at i! E9ui$ment. delivered at a $articular moment in t#e Dr. Maron re$orts receiving consulting cardiac cycle, even innocent%a$$earing !ees !rom JeneD. &a su"sidiary o! Bio% $recordial "lows can trigger ventricular ! ;e!erence (a"oratories' and lecture !ees i"rillation and result in !atal com% and grant su$$ort !rom Medtronic. Dr. Estes re$orts t#at #is institu% tion #as received !ellows#i$ !unding !rom 3t. Jude Medical, Boston 3cienti! ic, and Medtronic and t#at #e #as received lec% ture !ees and travel su$$ort !rom Boston 3cienti! ic. Qe t#ank David Mottet !or #is assistance wit# an earlier ver% sion o! 7igure 6.
)eference s
. Maron BJ, 2oliac (, Aa$lan JA, Mueller 7I. Blunt im$act to t#e c#est leading to sudden deat# !rom cardiac arrest during s$orts activities. N Engl J Med *++5=:::@ ::-%46. 2. Maron BJ, Jo#man )E, Ayle 3B, Estes NAM III, (ink M3. Clinical $ro! ile and s$ectrum o! commotio cordis. JAMA 6//6= 60-@**46%,. 3. 3c#lomka J, <inric#s A. E.$erimen% telle >ntersuc#ungen u"er den Ein! luss stum$!er Brustkor"verlet1ungen au! das Elektrokardiogramm. R Jes E.$ Med *+:6=:*@4:%,*. 4. 3c#lomka J. Commotio cordis und i#re 7olgen@ Die einwirkung stum$!er Brustwandtraumen au! das <er1. Erge" Inn Med Ainder#eilkd *+:4=4-@*%+*. 5. Cas$er J(. 2raktisc#es <and"uc# der Jeric#tlic#en Medi1in. Berlin@ erlag von August <irsc#wald, *05-. 6. Nes"itt AD, Coo$er 2J, Ao#l 2. ;edis% covering commotio cordis. (ancet 6//*= :5-@**+5%-. 7. Aelly M. Deat# touc#@ t#e science "e% #ind t#e legend o! Dim%Mak. Boulder, CI@ 2aladin 2ress, 6//*. 8. 7ra1er M, Mirc#andani <. Commotio cordis, revisited. Am J 7orensic Med 2at#ol *+04=5@64+%5*. 9. Meola 7. (a commo1ione toracica. Jior Interna1 3ci Med *0-+=*@+6:%:-. :. Maron BJ, Doerer JJ, <aas )3, Estes 3. Dickman JI, <assan A, (uckstead entricular ! i"rillation !ollowing E7. "ase"all2#ysician 3$orts Med injury. *+-0=,@05% ,. 4. Jreen ED, 3imson (; Jr, Aellerman <<, <orowit1 ;N, 3turner QN. Cardiac concussion !ollowing so!t"all "low to t#e Ann Emerg Med *+0/=+@*55%-. c#est. 5. Rangwill 3D, 3tras"urger J7. Commo% tio cordis. 2ediatr Clin Nort# Am 6//4= 5*@*:4-%54. 6. Boden B2, )acc#etti ;, Mueller 7I. Catastro$#ic injuries in #ig# sc#ool and college "ase"all $layers. Am J 3$orts Med 6//4=:6@**0+%+,. 7. Maron BJ. 3udden deat# in young at#% letes. N Engl J Med 6//:=:4+@*/,4%-5. 8. Maron BJ, Doerer JJ, <aas )3, )ierney DM, Mueller 7I. 3udden deat#s in young com$etitive at#letes@ analysis o! *0,, deat#s in t#e >nited 3tates, *+0/%6//,. Circulation 6//+=**+@*/05%+6. 9. Maron BJ, Doerer JJ, <aas )3, Estes III, <odges J3, (ink M3. NAM Commotio cordis and t#e e$idemiology o! sudden deat# in com$etitive lacrosse. 2ediatrics 6//+=*64@+,,%-*. 2:. (ink M3, Qang 2J, 2andian NJ, et al. An e.$erimental model o! sudden deat# due to low%energy c#est%wall im$act &commotio cordis'. N Engl J Med *++0= ::0@*0/5%**. 2 . (ink M3, Qang 2J, anderBrink BA, et

duced risk o! sudden deat# !rom wall c#est"lows &commotio cordis' wit# sa!ety "ase"alls. 2ediatrics 6//6=*/+@0-:%-. 24. (ink M3, Maron BJ, Qang 2J, ander% Brink BA, R#u Q, Estes NAM III. >$$er and lower limits o! vulnera"ility to sud%arr#yt#mic deat# wit# c#est wall den im% &commotio cordis'. J Am Coll $act Cardiol 6//:=4*@++%*/4. 25. Qeinstock J, Maron BJ, 3ong C, Mane 22, Estes NAM III, (ink M3. 7ailure o! commercially availa"le c#est wall $rotec% tors to $revent sudden cardiac deat# in% duced "y c#est wall "lows in an e.$eri% mental model o! commotio cordis. 6//,=**-&4'@e,5,%e,,6. 2ediatrics 26. Ao#l 2, Nes"itt AD, Coo$er 2J, (ei M. 3udden cardiac deat# "y commotio cordis@ role o! mec#ano%electric !eed"ack. Car% diovasc ;es 6//*=5/@60/%+. 27. Bode 7, 7ran1 M;, Qilke I, Bon% nemeier <, 3c#unkert <, Qiegand >A. entricular ! i"rillation induced "y stretc#im$lications !or sudden deat# $ulse@ due to commotio cordis. J Cardiovasc Electro%6//,=*-@*/**%-. $#ysiol 28. Coo$er JJ, 2earce B2, 3tainer MC, Maynard ;(. )#e "iomec#anical res$onse o! t#e t#ora. to non$enetrating im$act wit# $articular re!erence to cardiac inju% J )rauma *+06=66@++4%*//0. ries. 29. (iedtke AJ, Allen ;2, Nellis 3<. E!% !ects o! "lunt cardiac trauma on coronary

NAM III, (ink M3. A #istorical o"serva%

al. 3elective activation o! t#e AS

tion on commotio cordis. <eart ;#yt#m 6//,=:@,/ 5%-. . ;ut#er!ord JQ, Aennedy J, McJ#ee (. Base"all and so!t"all related injuries to c#ildren 5%*4 years o! age. Qas#ington, DC@ Consumer 2roduct 3a!ety Commis% sion, *+04. 2. A"run1o )J. Commotio cordis@ t#e single, most common cause o! traumatic deat# in yout# "ase"all. Am J Dis C#ild *++*=*45@*6 -+%06.

c#an nel is a mec#anism "y w#ic# sudden deat# is $roduced "y low energy c#est wall im$act &commotio cordis'. Circulation *+++=*//@ 4*:% 0. 22. (ink M3, Maron BJ, 3tickney ;E, et al. Automated e.ternal de! i"rillator arr#yt#% mia detection in a model o! cardiac arrest due to commotio cordis. J Cardiovasc Electro$#ysiol 6//:=*4@0:%-. 23. (ink M3, Maron BJ, Qang 2J, 2andian NJ, anderBrink BA, Estes NAM III. ;e%

vasomotion, $er!usion, myocardial me% c#anics, and meta"olism. J )rauma *+0/= A)2 6/@---% 05. 3:. Madias C, Maron BJ, 3u$ron 3, Estes NAM III, (ink M3. Cell mem"rane stretc# and c#est "low% induced ventricular ! i"ril% lation &commotio cordis'. J Cardiovasc Electro$#ysiol 6//0=*+@*:/4%+. 3 . Jaran A;, Maron BJ, Qang 2J, Estes NAM III, (ink M3. ;ole o! stre$tomycin% sensitive stretc# activated c#annel in c#est wall im$act induced sudden deat# &com%

n engl j med :,6=*/

+65

nejm.org marc# **, 6/*/

T he n e w e n g l an d j o u r n al of m e d ic i n e motio cordis'. J Cardiovasc Electro$#ysiol 6//5=*,@ 4::%0. 32. 3tout CQ, Maron BJ, ander"rink BA, Estes NAM III, (ink M3. Im$ortance o! t#e autonomic nervous system in an e.% $erimental model o! commotio cordis. Med 3ci Monit 6//-=*:@B;**% B;*5. 33. (ink M3, Maron BJ, anderBrink BA, et al. Im$act directly over t#e cardiac sil% #ouette is necessary to $roduce ventricu% lar ! i"rillation in an e.$erimental model o! commotio cordis. J Am Coll Cardiol 6//*=:-@, 4+%54. 34. iano DC, Bir CA, C#eney AA, Janda D<. 2revention o! commotio cordis in "ase"all@ an evaluation o! c#est $rotec% tors. J )rauma 6///=4+@*/6:%0. 35. (iedtke AJ, Jault J<, Demut# QE. Electrocardiogra$#ic and #emodynamic c#anges !ollowing non$enetrating c#est trauma in t#e e.$erimental animal. Am J 2#ysiol *+-4=66,@:--%06. 36. <amilton 3J, 3unter J2, Coo$er 2N. Commotio cordis G a re$ort o! t#ree cases. Int J (egal Med 6//5=**+@00% +/. 37. )i""alls J, )#iruc#elvam ). A case o! commotio cordis in a young c#ild caused "y a !all. ;esuscitati on 6//0=--@*: +%4*. 38. (ucena J3, ;ico A, 3alguero M, Blanco M, T19ue1 ;. Commotio cordis as a re% sult o! a ! ig#t@ re$ort o! a case considered to "e im$rudent #omicide. 7orensic 3ci Int 6//0=*--&* '@e*%e4. 39. Crown (A, <awkins Q. Commotio cordis@ clinical im$lication s o! "lunt car% diac trauma. Am 7am 2#ysician *++-=55@ 6 4 , % / . 4:. Deady B, Innes J. 3udden deat# o! a young #ockey $layer@ case re$ort o! com% motio cordis. J Emerg Med *+++=*-@45+ %,6. 4 . Qang J% N, )sai K%C, C#en 3%(, C#en K, (in C%3, Qu J% M. Dangerous im$act G commotio cordis. Cardiology 6///=+:@ * 6 4 % , . 42. )#akore 3, Jo#nston M, ;ogena E, 2eng R, 3adler D. Non% $enetrating c#est "lows and sudden deat# in t#e young. J Accid Emerg

Med 6///=*-@46*%6. 43. Edlic# ;7 Jr, Mayer NE, 7ariss B(, et al. Commotio cordis in a lacrosse goalie. J Emerg Med *+0-=5@*0*%4. 44. 2earce 2R. Commotio cordis@ sudden deat# in a young #ockey $layer. Curr 3$orts Med ;e$ 6//5=4@*5-%+. 45. Maron BJ, Mitten MJ, Jreene Burnett C. Criminal conse9uences o! commotio cordis. Am J Cardiol 6//6=0+@6*/%:. 46. Denton J3, Aalelkar MB. <omicidal commotio cordis in two c#ildren. J 7oren% sic 3ci 6///=45@-:4%5. 47. Boglioli (;, )a!! M(, <arleman J. C#ild #omicide caused "y commotio cordis. 2ediatr Cardiol *++0=*+@4:,%0. 48. Baker AM, Craig B;, (onergan JJ. <omicidal commotio cordis@ t#e ! inal "low in a "attered in!ant. C#ild A"use Negl 6//:=6-@*65%:/. 49. 7roede ;C, (indsey D, 3tein"ronn A. 3udden une.$ected deat# !rom cardiac

concussion &commotio cordis' wit# un% usual legal com$lications. J 7orensic 3ci *+-+=64@ -56%,. 5:. (ink M3, Jins"urg 3<, Qang 2J, Airc#lo!!er JB, Estes NAM III, 2arris KM. Commotio cordis@ cardiovascular mani!es% tation o! a rare survivor. C#est *++0=**4@ :6, %0. 5 . Maron BJ, 3tras"urger J7, Augler JD, Bell BM, Brodkey 7D, 2oliac (C. 3urvival !ollowing "lunt c#est im$act%induced cardiac arrest during s$orts activities in young at#letes. Am J Cardiol *++-=-+@ 04/ %*. 52. Maron BJ, 2elliccia A. )#e #eart o! trained at#letes@ cardiac remodeling and t#e risks o! s$orts including sudden deat#. Circulation 6//,=**4@*,::%44. 53. iano DC, Andr1ejak D , 2olley )R, Aing AI. Mec#anism o! !atal c#est injury "y "ase"all im$act@ develo$ment o! an e.% $erimental model. Clin J 3$ort Med *++6= 6@*,, %-*. 54. Drewniak EI, 3$enciner DB, Crisco JJ. Mec#anical $ro$erties o! c#est $rotectors and t#e likeli#ood o! ventricular ! i"rilla% tion due to commotio cordis. J A$$l Bio% mec# 6//-=6:@606%0.

55. Bir CA, iano DC. Biomec#anical $re% dictor o! commotio cordis in #ig#% s$eed c#est im$act. J )rauma *+++=4-@4,0%-:. 56. (ink M3, Bir C, Dau N, Madias C, Estes NAM III, Maron BJ. 2rotecting our c#il% dren !rom t#e conse9uences o! c#est "lows on t#e $laying ! ield@ a time !or sci% ence over marketing. 2ediatrics 6//0=*66@ 4:-% +. 57. Bek#eit 3%3, ;estivo M, Boutjdir M, et al. E!!ects o! gly"uride on isc#emia% induced c#anges in e.tracellular $otassium and local myocardial activation@ a $otential new a$$roac# to t#e management o! is% c#emia% induced malignant ventricular ar% r#yt#mias. Am <eart J *++/=**+@*/65% ::. 58. Au"ota I, Kamaki M, 3#i"ata ), Ikeno E, <osoya K, )omoike <. ;ole o! A)2% sensitive AS c#annel on ECJ 3) segment elevation during a "out o! myocardial isc#emia@ a study on e$icardial ma$$ing in dogs. Circulation *++:=00@*045% 5*. 59. Aondo ), Au"ota I, )ac#i"ana <, Ka% maki M, )omoike <. Jli"enclamide atten% uates $eaked ) wave in early $#ase o! myocardial isc#emia. Cardiovasc ;es *++,= :*@,0: %-. 6:. Aantor 27, Coet1ee QA,

Carmeliet EE, Dennis 3C, I$ie (<. ;eduction o! is% c#emic AS loss and arr#yt#mias in rat #earts@ e!!ect o! gli"enclamide, a sul!onyl% urea. Circ ;es *++/=,,@4-0%05. 6 . an Qagoner D;. Mec#anosensitive gating o! atrial A)2%sensitive $otassium c#annels. Circ ;es *++:=-6@+-:%0:. 62. )uritto J, Dini 2, 2rati 2(. )#e ; on ) $#enomenon during transient myocardi% al isc#emia. Am J Cardiol *+0+=,:@*56/% 6. 63. <aUssaguerre M, E.tramiana 7, <oci% ni M, et al. Ma$$ing and a"lation o! ven% tricular ! i"rillation associated wit# long%

N) and Brugada syndromes. Circulation 6//:=*/ 0@+65%0. 64. 3#imi1u Q, Ant1elevitc# C. Cellular "asis !or t#e ECJ !eatures o! t#e (N)* !orm o! t#e long%N) syndrome@ e!!ects o! "eta%adrenergic agonists and antagonists and sodium c#annel "lockers on trans% mural dis$ersion o! re$olari1ation and torsade de $ointes. Circulation *++0=+0@ 6:* 4% 66. 65. iswanat#an 2C, ;udy K. Cellular ar% r#yt#mogenic e!!ects o! congenital and ac9uired long N) syndromes in t#e #etero% geneous myocardium. Circulation 6///= */*@* *+6% 0. 66. Jussak I, Ant1elevitc# C, Bjerregaard 2, )ow"in JA, C#aitman B;. )#e Brugada syndrome@ clinical, electro$#ysiologic and genetic as$ects. J Am Coll Cardiol *+++= ::@ 5% *5. 67. Kan JV, Ant1elevitc# C. Cellular "a% sis !or t#e Brugada syndrome and ot#er mec#anisms o! arr#yt#mogenesis associ% ated wit# 3)%

segment elevation. Circula% tion *+++=*//@*,,/%,. 68. Ant1elevitc# C, Iliva A. Am$li! ica% tion o! s$atial dis$ersion o! re$olari1a% tion underlies sudden cardiac deat# asso% ciated wit# catec#olaminergic $olymor$#ic ), long N), s#ort N) and Brugada syn% dromes. J Intern Med 6//,=65+@40%50. 69. 3tras"urger J7, Maron BJ. Commotio cordis. N Engl J Med 6//6=:4-@*640. 7:. Doerer JJ, <aas )3, Estes NAM III, (ink M3, Maron BJ. Evaluation o! c#est "arriers !or $rotection against sudden deat# due to commotio cordis. Am J Car% diol 6//-=++@05-%+. 7 . Janda D<, iano DC, Andr1ejak D , <ensinger ;N. An analysis o! $reventive met#ods !or "ase"all%induced c#est im% $act injuries. Clin J 3$ort Med *++6=6@ *-6 %+. 72. Aa$lan JA, Aaro!sky 23, olturo JA. Commotio cordis in two amateur ice #ockey $layers des$ite t#e use o! commer% cial c#est $rotectors@ case re$orts. J )rau% ma *++:=:4@*5*%:. 73. Myer"urg ;J, Estes NAM III, 7ontaine JM, (ink M3, Ri$es D2. )ask 7orce */@ automated e.ternal de! i"rillators. J Am Coll Cardiol 6//5=45@*:,+%-*.

74. (ee C%C, C#ang Q%), C#en 3%C, Ken R%3, C#en Q%J. 3uccess!ul resuscitation a!ter sudden deat# in a one year old in!ant w#o sustained a "lunt c#est injury !rom a !all !rom */ m. ;esuscitation 6//5=,4@ 64*%:. 75. 3ali" EA, Cyran 3E, Cilley ;E, Maron BJ, )#omas NJ. E!! icacy o! +6 ,

"ystander car% dio$ulmonary resuscitation and out%o!% #os$ital automated e.ternal de! i"rillation as li!e%saving t#era$y in commotio cordis. J 2ediatr 6//5=*4-@0,:%,.

76. Maron BJ, Qent1el DC, Renovic# AJ, Estes NAM III, (ink M3. Deat# in a young at#lete due to commotio cordis des$ite $rom$t e.ternal de! i"rillation. <eart ;#yt#m 6//5=6@++*%:.

n engl j med :,6=*/

nejm.org marc# **, 6/*/

Medic al 2rogr ess 77. Amir I, 3c#liamser JE, Nemer 3, Arie M. Ine!!ectiveness o! $recordial t#um$ !or cardioversion o! malignant ventricular tac#yarr#yt#mias. 2acing Clin Electro% $#ysiol 6//-=:/@*5:%,. 78. E! imov I;, 7edorov . 2recordial t#um$ and commotio cordis@ t#e yin and yang o! mec#anoelectric !eed"ack in t#e #eart. <eart ;#yt#m 6//,=:@*0-%0. 79. Miller JM, B#akta D. )#e $recordial t#um$@ convertio cordis, commotio cordis, or neit#erW 2acing Clin Electro$#ysiol 6//-=:/@ *5*%6. 8:. 2ellis ), Aette 7, (ovisa D, et al. >tility o! $re%cordial t#um$ !or treatment o! out o! #os$ital cardiac arrest@ a $ros$ective study. ;esuscitation 6//+=0/@*-% 6:. 8 . <aman (, 2ari1ek 2, ojacek J. 2recor% dial t#um$ e!! icacy in termination o! in% duced ventricular arr#yt#mias. ;esuscita% tion 6//+=0/@*4%,. 82. Madias C, Maron BJ, Als#eik#%Ali AA, ;aja" M, Estes NAM III, (ink M3. 2recor% dial t#um$ !or cardiac arrest is e!!ective !or asystole "ut not !or ventricular ! i"ril% lation. <eart ;#yt#m 6//+=,@*4+5%5//. Copyright 2010 Massachusetts Medical Society.

n engl j med :,6=*/

+6-

nejm.org marc# **, 6/*/