March 30, 2004

Experts Discuss Rare Heart Phenomenon

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The recent and sudden death of men’s lacrosse co-captain George Boiardi ’04 highlights the rising dangers of a phenomenon only recently known as commotio cordis.

Commotio cordis had been recorded in medical journals as far back as the nineteenth century — but had not been fully studied, understood, or named until recently.

In the past five years, there have been four lacrosse players’ deaths attributed to this condition and six total recorded events, which are characterized by a sudden blunt trauma to the heart that causes an arrhythmia. This in turn leads to a sudden cardiac arrest.

The effects of Boiardi’s death have rippled throughout the lacrosse community, with games across the country beginning with moments of silence in order to celebrate his memory.

As the laxer’s death has caused the lacrosse community great pain, many have taken to discussing the details — and sometimes rumors — that are inconsistent with the coverage relating to his death.

Boiardi fell to the ground after being struck in the chest with a lacrosse ball during the fourth quarter of a game between the Red and Binghamton. Paramedics performed CPR and administered defibrillation to Boiardi, but were unable to resuscitate him. He was pronounced dead at 6:44 p.m. on March 17 at Cayuga Medical Center.

The Boiardi family has asked that information regarding the cause of death not be released to the public, and his death has not been officially attributed to commotio cordis.

The family has requested that no autopsy be performed, and, without one, the cause of Boiardi’s death will remain mysterious. According to Sharon Dittman, associate director of Gannett Health Center, because no post-mortem will be performed, there is no way to know for sure what caused Boiardi’s death.

This has not stopped many people from speculating.

Dr. Barry Maron, director of the Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute and a leading researcher on the topic of commotio cordis, said that without an autopsy, the “best inference” is that Boiardi died of the medical phenomenon.

Most experts in the field of cardiology have agreed with Maron, including Tufts University professor of medicine and leading commotio cordis researcher Dr. Mark Link, and Frederick Mueller, director of the National Center for Catastrophic Sports Injury Research.

However, this conclusion is not universally accepted.

John Desko, the head coach of the Syracuse men’s lacrosse team, in a recent Daily Orange article, challenged the assumption that Boiardi died of commotio cordis, citing the fact that Boiardi bled after being hit, a characteristic not usually associated with this condition. He also stated that Boiardi had been hit in the side rather than in the chest.

Desko did not return The Sun’s calls to his office.

“There is absolutely no evidence of any of that. There was no substantial blood and no obvious damage to the heart,” Dittman said.

According to Dittman and discussions with other eyewitness accounts, the ball did strike Boiardi in the chest.

She said that there was no clear sign from where the blood came from, and added that, “there was not enough blood to bleed to death, and he died too quickly to have died from internal bleeding.”

She speculated that the blood could have come from another trauma, possibly due to his fall to the turf.

Maron based his comments on the details released in news stories covering the death of Boiardi, which make no reference to bleeding.

According to Maron, who wrote the “modern description of commotio cordis” in a 1995 paper published in the New England Journal of Medicine, the condition is highly random and contingent on the convergence of three factors: location, timing, and shape of chest.

Link added that whether someone suffers commotio cordis also relies on the softness of the chest.

According to Maron, for a blow to the chest to result in commotio cordis, it must exactly hit the heart at a precise time during its cycle. In addition, the shape of the chest tends to be narrow.

Since 1995, Maron and his associates have recorded 160 cases of commotio cordis. The phenomenon is not distinct to lacrosse; it also affects softball, hockey, football. It strikes baseball with the highest frequency.

There have even been seven felony convictions involving cases of commotio cordis, said Maron. In all those cases, the defendant was either found guilty of first degree murder or it was plea bargained down to manslaughter. Maron said this reinforces the idea that this phenomenon not only affects the athlete, but also people performing normal activities.

It is, however, most common in youth athletics — the highest frequency being 13-year-old boys. Maron cautioned that this is most likely a factor of exposure and not of their age.

According to Link, 90 percent of cases of commotio cordis are recorded in youths under the age of 16. This is due in part to the relative softness of the tissue in and surrounding the heart.

Steve Stenerson, executive director of U.S. Lacrosse, the governing body of lacrosse in the United States, spoke of how the base of the pyramid of competitive athletics in the United States is made up of youth groups.

U.S. Lacrosse has become increasingly interested in this dangerous and hard to understand phenomenon.

“This is a very significant issue for us, but we must resist the emotional response to say, ‘We must do something immediately,'” he said.

He spoke of following courses of action such as working with other entities like the NCAA, and the NFSHA, looking at recent research, and considering the “biomechanical component.”

U.S. Lacrosse and Maron are investigating whether or not a redesign of currently used chest protectors could sufficiently protect players from incidence of commotio cordis. Three of the five recent fatalities were goalies who are required to wear chest protectors.

U.S. Lacrosse also supports the efforts of the Louis J. Acompora Memorial Foundation, founded by the parents of Louis J. Acompora, a high school goalie who died of commotio cordis in 2000, in lobbying and advocating for the placement of automatic external defibrillators (AED) at all lacrosse sights.

Cornell recently invested in AED units, and one was used in Boiardi’s case. In perhaps the most famous case of commotio cordis, a youth baseball player was resuscitated by a police officer who happened to be driving by the site of incidence with a AED unit. An inside fastball had struck the 13-year-old directly above the chest, and had resulted in cardiac arrest.

According to Link, if a victim is defibrillated within five minutes of incidence, there is a high probability of survival. Boiardi was defibrillated within a minute to a minute and half after being struck, Dittman said.

Maron said that the average rate of survival of someone affected by commotio cordis is 15 percent. Researchers believe application of an AED is the best manner to revive a commotio cordis victim.

Stenerson emphasized as did Maron that many players are struck in the chest every week without a single case of commotio cordis.

Stenerson reiterated, “There is no immediate answer.”

Archived article by Michael Margolis
Sun Senior Writer