EXPERIMENTAL STUDY
Impact directly over the cardiac silhouette is necessary to produce ventricular fibrillation in an experimental model of commotio cordis
Mark S. Link, MD, FACC*,
Barry J. Maron, MD, FACC ,
Brian A. VanderBrink, BS*,
Masaaki Takeuchi, MD*,
Natesa G. Pandian, MD, FACC*,
Paul J. Wang, MD, FACC* and
N. A. Mark Estes, III, MD, FACC*
* Center for the Cardiovascular Evaluation of Athletes, The Cardiac Arrhythmia Center, New England Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
Cardiovascular Research Division, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
Manuscript received May 23, 2000;
revised manuscript received September 14, 2000,
accepted October 18, 2000.
Reprint requests and correspondence: Dr. Mark S. Link, New England Medical Center, NEMC Box #197, 750 Washington Street, Boston, Massachusetts 02111
MLink{at}Lifespan.org
OBJECTIVES
In an experimental model of sudden death from chest wall impact (commotio cordis), we sought to define the chest wall areas important in the initiation of ventricular fibrillation (VF).
BACKGROUND
Sudden death can result from an innocent chest blow by a baseball or other projectile. Observations in humans suggest that these lethal blows occur over the precordium. However, the precise location of impact relative to the risk of sudden death is unknown.
METHODS
Fifteen swine received 178 chest impacts with a regulation baseball delivered at 30 mph at three sites over the cardiac silhouette (i.e., directly over the center, base or apex of the left ventricle [LV]) and four noncardiac sites on the left and right chest wall. Chest blows were gated to the vulnerable portion of the cardiac cycle for the induction of VF.
RESULTS
Only chest impacts directly over the heart triggered VF (12 of 78: 15% vs. 0 of 100 for noncardiac sites: p < 0.0001). Blows over the center of the heart (7 of 23; 30%) were more likely to initiate VF than impacts at other precordial sites (5 of 55; 9%, p = 0.02). Peak LV pressures generated instantaneously by the chest impact were directly related to the risk of VF (p < 0.0006).
CONCLUSIONS
For nonpenetrating, low-energy chest blows to cause sudden death, impact must occur directly over the heart. Initiation of VF may be mediated by an abrupt and substantial increase in intracardiac pressure. Prevention of sudden death from chest blows during sports requires that protective equipment be designed to cover all portions of the chest wall that overlie the heart, even during body movements and positional changes that may occur with athletic activities.
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Abbreviations and Acronyms
| | ECG | = electrocardiogram | | LV | = left ventricle, left ventricular | | VF | = ventricular fibrillation |
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