Commotio cordis

A 22-year-old man, Mr X, and his friend, were playing a game of softball. His friend (as batsman) accidentally struck the ball into Mr X's chest. Mr X subsequently collapsed and lost consciousness. Cardiopulmonary resuscitation began following the arrival of paramedics. The patient was found in ventricular fibrillation and defibrillated to sinus rhythm. Upon arrival in the emergency department, the patient remained unresponsive but haemodynamically stable. An echocardiogram was performed which showed no structural abnormalities, pericardial effusions or valvular damage. The patient soon reverted back to ventricular fibrillation and despite the best efforts of the medical team could not be revived. An autopsy was warranted which indicated no evidence of injury or natural disease to account for his death. A section from the autopsy report is as follows: ‘The heart weighs 316 g. The pericardial sac is free of significant fluid or adhesions. The coronary arteries arise normally and follow the distribution of a right dominant pattern with no significant atherosclerosis. The chambers and valves are proportionate. The valves are normally formed, thin and pliable and free of vegetations and degenerative changes. The myocardium is dark red brown, firm and free of focal or regional fibrosis, erythema, pallor or softening. The atrial and ventricular septa are intact and the septum and free walls are free of muscular bulges.' Microscopic assessment of the heart as well as toxicological analysis of the blood proved unremarkable. The medical examiner assigned commotio cordis as the immediate cause of death.