Matters of the Heart: A Comprehensive Look at Commotio Cordis, and What is Being Done to Prevent It

In March 2000, Louis Acompora was a goalie on the Northport (N.Y.) High School freshman lacrosse team. He likely shared the same hopes that many other 14-year-old players harbor: enjoy a good season, improve on his skills and prepare to join the varsity team in future seasons.

Sadly, Acompora never had a chance to realize those goals.

During a game, Acompora absorbed a shot that hit him in the chest. Despite wearing a chest protector, the impact of the ball sent him into cardiac arrest. Coaches and officials performed CPR on site, but Acompora was pronounced dead-on-arrival at the hospital.

Following his death, Louis’ parents — Karen and John — learned that the rare incident that claimed their son’s life actually has a name: commotio cordis. It occurs when an individual receives a blow to the chest in a very precise spot over the heart at a very precise moment in the cardiac cycle. The blunt blow — which doesn’t even need to have extreme force — imparts an electric charge to the heart, causing ventricular fibrillation in an otherwise normal heart.

The Acomporas also learned that their son might have survived if Northport had had an automated external defibrillator, commonly known as an AED, onsite. These portable machines help increase the likelihood of surviving sudden cardiac arrest (SCA) by shocking the heart back into its normal rhythm.

Data collected by Dr. Barry Maron of the Minneapolis Heart Institute chronicles 188 cases of commotio cordis, encompassing a variety of sports-related and non-sports-related instances. His findings reveal that victims who receive defibrillation within one to two minutes of sustaining impact have the best chance for survival. Additionally, the data suggest that early CPR application is just as important as early AED application in helping victims survive.

What’s Being Done

US Lacrosse recently took a leadership role among sport-based organizations in addressing commotio cordis.

“Injury research shows that lacrosse is a relatively safe sport to play, but the risk of catastrophic injury still exists, as it does in every sport,” said Steve Stenersen, executive director of US Lacrosse. “In the rare case of a commotio cordis episode, or if SCA should afflict a spectator or official, the prompt and proper use of an AED greatly increases the odds of the victim’s survival.”

In May, the organization hosted the first commotio cordis summit in Baltimore, bringing together leading researchers, medical experts and equipment manufacturers. The Acomporas, along with two other lacrosse families that have been victimized by commotio cordis — the Boiardis and the Macks — were among those in attendance.

George Boiardi was a senior defenseman at Cornell when he was stuck in the chest by a ball during a game in March 2004. He lost consciousness and, despite resuscitation efforts that included the application of CPR and an AED, passed away. An autopsy was not performed, but many believe commotio cordis caused his death.

John Mack was a 17-year-old player at Binghamton (N.Y.) High. During an indoor game in late November 2006, he was struck in the chest by a stick. He spent two days in a hospital on life support before passing.

“We are committed to the health and safety of all lacrosse players,” said Dr. Vito Perriello, a member of US Lacrosse’s Sports Science and Safety Executive Committee. “We will not rest until this is where it should be.”

Among the conclusions reached by summit participants was that greater knowledge of and access to AEDs was critical to countering commotio cordis. US Lacrosse has committed to simplifying the process for schools, teams and leagues to obtain AEDs.

The organization recently announced a strategic alliance with Cardiac Science Corporation to increase the awareness and availability of AEDs to its members and affiliated programs (see sidebar).

“We encourage lacrosse organizations around the country to purchase AEDs as an additional step in the quest to provide the safest possible environment for players, coaches, officials and spectators,” said Stenersen.

Since Louis’ death, the Acomporas have taken a leading role in increasing the access to AEDs. They established the Louis Acompora Foundation, the primary mission of which is to lobby all states to pass laws requiring schools to have a defibrillator. In 2002, New York became the first state to pass such a law.

“These machines are of obvious benefit after a [commotio cordis] event occurs,” Maron said.

Checking Gear

Summit participants also concurred that continued work towards the prevention of commotio cordis incidents is as important as treatment.

“Prevention is the best method and our ultimate goal,” said Perriello. “Discovering what materials are the most effective is the goal.”

The research of Dr. Mark Link of the New England Medical Center and Dr. Cynthia Bir of Wayne State University — who have used animal surrogates and mechanical models to study the causes of commotio cordis — is providing equipment manufacturers with greater understanding of the phenomenon. Initial findings indicate that two contributing factors in occurrences of commotio cordis are the density of the impact object and the ability of the protective device to dissipate the energy of the impact.

Using that data, equipment manufacturers can pursue chest protector design variances that may help curb future incidents. Prototypes with air pockets or shape geometries that dissipate and reflect force are being considered. Developing softer balls, especially for use in youth baseball and lacrosse leagues, also remains an option.

Kyle Sweeney, a member of the U.S. men’s team and a vice president at equipment manufacturer Maverik, attended the summit. He said that the information is still far from conclusive and that making equipment changes now would be premature.

“There was nothing that we could take away from that meeting regarding changes in protection,” said Sweeney. “There’s lots of research being done, but no real answer. There are so many variables that come into play on this issue. I’m glad I was there, even if it was just to confirm that we don’t have an answer yet.”

Dale Kohler, general manager for Brine, also attended the summit.

“More evidence needs to be compiled, and we need to keep working the problem,” said Kohler. “We’re all touched by the tragedy of commotio cordis, and there is no denying that it is happening. We walked away from the summit compelled to do something. We just don’t know what that is yet.”

The National Operating Committee on Standards for Athletic Equipment (NOCSAE) determines specifications for equipment. With commotio cordis research still incomplete, no current standard for chest protectors has been established. Lacking that standard, a national governing body, like US Lacrosse, cannot modify its rule book.

“The tough part is waiting for the science,” said Dr. Trey Crisco, director of the bioengineering laboratory in the department of orthopaedics at Brown Medical School and Rhode Island Hospital. “Once you figure out the science, establishing the standard is pretty cut and dried.”

Crisco said that mandating and enforcing the use of non-compromised equipment would go hand-in-hand with its production. Players would be prohibited from altering the protective gear to make it more comfortable, lightweight or form-fitting.

“Once adopted, compliance is done by self-certification by the manufacturers,” said Crisco.

“We’ve got to continue to build on these points of discussion,” said Dr. Fred Mueller of the Center for Catastrophic Sport Injury and a member of the US Lacrosse Sports Science and Safety Executive Committee. “Does equipment that appears effective in the lab also work in the field? Will organizations accept a mandate to use this equipment? Will manufacturers produce it?”

In many respects, the summit created more questions than it answered. Nevertheless, all participants agreed that the issues surrounding this phenomenon need to be explored further, with continued research, product testing and education, to make the sport safer.

For more information on AEDs and the partnership between US Lacrosse and Cardiac Science, including the special pricing options, visit www.uslacrosse.org or www.cardiacsciencepartners.com/usl.