By Christopher Madias, MD
Warm weather is upon us … finally. With the arrival of long sun-filled days, my mind immediately turns to thoughts of summer – including ice cream cones, strolling on the beach and, of course, baseball.
There is little I find more relaxing in life than grilling burgers on our deck at home with the distant sounds of baseball being played on our television in the background. Better yet is having a hot dog and cold drink in hand while shooting the breeze through nine innings at a ballgame with my wife or a close friend. There is just something about baseball that makes it the ultimate warm-weather sport. Strolling through our neighborhood in the summer, there are constantly little league and softball games being played on the fields near our home, and I always find myself stopping to watch even a few pitches.
I am usually lulled into an immediate state of relaxation from the sights and sounds of a baseball game – the colorful uniforms, the crack of a bat hitting a ball, and the faint sound of the bell from the ice cream truck on the corner. However, because of my research background, my mind sometimes wanders, and it always strikes me to think that rarely, such an idyllic setting can suddenly turn to one of tragedy on a single pitch.
As a cardiac electrophysiologist (heart rhythm specialist), one of my research interests has been sudden cardiac death in athletes. Fortunately, the death of an athlete is an extremely rare phenomenon; however, when it occurs, it is always a tragic, devastating event. It just doesn’t seem right that a young person, who is otherwise the embodiment of health, could suddenly collapse on the playing field. Usually sudden death in athletes is caused by lethal heart arrhythmias that occur in children and young adults who unknowingly have an unrecognized underlying heart disorder. The most common abnormality is an inherited disorder that results in abnormal thickening of the heart called hypertrophic cardiomyopathy.
The area of my research has been in an even more rare cause of sudden death in athletes called commotio cordis. Commotio cordis is defined as sudden death caused by a lethal heart rhythm that is triggered by a blunt blow to the chest. Most commonly such blows occur in sports such as baseball, hockey or lacrosse, where a small dense ball (or puck) is used in the game.
My interest in commotio cordis started during my training at Tufts Medical Center in Boston. One of my mentors, Dr. Mark Link is a pioneer in the field of commotio cordis and has helped bring to light the underlying origins of this mysterious phenomenon. Unlike most other causes of sudden death in athletes, commotio cordis occurs in completely healthy individuals without any underlying heart disorders. The main reason commtio cordis is such a rare phenomenon is that it takes a confluence of several specific factors to trigger an event. An impact of a particular force (not too hard or too soft) has to occur directly over the heart. In addition, and most importantly, this impact must occur during a very narrow time period during the cardiac cycle when the heart is susceptible to initiation of these dangerous arrhythmias.
Most Common in Baseball, Softball
Commotio cordis most commonly occurs in children and young adults between the ages of 10 to 20 years old. By far, the most common sports in which commotio cordis has been reported have been baseball and softball. Other sports have included ice hockey, lacrosse, football, basketball, cricket, martial arts and boxing.
When commotio cordis events occur, they are unfortunately most often fatal. One reason for the poor overall survival rate is the lack of understanding and recognition of this phenomenon. The chest blows that trigger commotio cordis are often so innocent appearing – not occurring with substantial force to cause any noticeable injury – that bystanders do not immediately appreciate the life-threatening nature of the collapse. If aggressive institution of cardiopulmonary resuscitation (CPR) and particularly defibrillation (shocking the heart back into normal rhythm) does not occur early, individuals usually will not survive. Increased awareness of commotio cordis is imperative, especially in those that might be first responders on the playing field such as parents, coaches, game officials and medical personnel. In addition, the increased presence of automated external defibrillators (AEDs) at athletic events should continue to improve the survival rate in commotio cordis as well as other causes of sudden death in athletes.
Early Defibrillation and Resuscitation are Key
Prevention of commotio cordis is a challenge. The use of safety baseballs (balls with softer cores) might be one way to reduce the risk of commotio cordis. Unfortunately, other currently available protective gear is not designed nor tested to prevent sudden death from chest impact. In fact, many commercially available chest protectors have been shown not to be effective barriers to commtio cordis. Creation of a more effective chest barrier is imperative and should be feasible in the near future.
Notably, I think it is important to realize again that commotio cordis, although tragic, is an extremely rare event. I would hate to see parents restrict children from participation in sport because of this issue. Athletics were such an important part of my life growing up and exercise remains an essential piece of an overall healthy life style. As my own baby girl grows, I can’t wait to play catch with her in our back yard and plan to encourage her to participate in sport throughout her childhood. However, as a health care provider and more importantly as a parent, I think it is all of our responsibility to make the playing field as safe a place as possible for our children. Hopefully, they will be able to take pleasure in the joys of summer in the same carefree way that we once did.