<HTML><BODY style="word-wrap: break-word; -khtml-nbsp-mode: space; -khtml-line-break: after-white-space; "><FONT class="Apple-style-span" face="Arial">Dr. Luciano Pereira from Paraguay asks</FONT><DIV><FONT class="Apple-style-span" face="Arial"><BR class="khtml-block-placeholder"></FONT></DIV><DIV><FONT class="Apple-style-span" face="Arial">- The Commotio Cordis is an entity increasingly being diagnosed over the last few years. Since it is highly deadly and affects young sportsmen in most cases, cardioverter defibrillators and other reanimation devices availability should not be obligatory in public and private institutions devoted to sports?</FONT><DIV><DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial"> </FONT></DIV></DIV><DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial">Dr. Andres Perez Riera from Brazil answers</FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial"><BR class="khtml-block-placeholder"></FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial">- Dear Luciano: Here Andrés Ricardo Pérez Riera from São Paulo Brazil. Cardiac concussion, commotio cordis, or nonpenetrating chest wall impact (traumatic blow to the chest wall causing VT/VF) is caused by a sudden, nonpenetrating, localized impact to the chest that is theorized to result in almost simultaneous SD from a disruption to the conductive system. Commotio cordis may lead to SCD due to the acute initiation of VF. VF may result from sudden stretch during a vulnerable window, which is determined by repolarization inhomogeneity. The detailed external/internal forensic examination of the body reveals no evidence of structural, pathologic, or histologic signs of trauma to the heart. A cardiac concussion is a rare and often overlooked cause of SD. This type of SD is typically seen among younger individuals participating in sports involving projectiles and, to a lesser degree, where collisions occur. Cardiac concussions are clinically, pathologically, and chemically different from a cardiac contusion1.</FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial"> </FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial">The main cause’s of SD among young athetes (<35 years old) are:</FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial"> </FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial">1) Hypertrophic cardiomyopathy (HCM) is the most common form of SD in young competitive athletes;</FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial"> </FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial">2) Arrhythmogenic right ventricular dysplasia (ARVD);</FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial"> </FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial">3) Anomalous coronary origins: White-Bland-Garlad syndrome and others;</FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial"> </FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial">4) Marfan syndrome;</FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial"> </FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial">5) Premature coronary artery disease;</FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial"> </FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial">6) Structurally normal heart (ion channel disorders.): SD with a structurally normal heart was the leading cause of death among female young recruits during military training2. These main entities are: congenital LQTS, the SQTS, BrS and CPVT. These are pathologies with very different phenotypes and aetiologies, but which share a common final pathway in causing SD: amplification of spatial dispersion of repolarization in the form of TDR(3).</FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial"> </FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial">7) Inflammatory myocardial diseases: Myocarditis</FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial"> </FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial">8) Commotio cordis.</FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial"> </FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial">Analyze the presence of myocardial damage in relation to official boxing matches. Low-energy chest wall impact could be responsible for SCD h, i.e. commotio cordis. As boxing is a traumatic sport in which thoracic hits usually occur, it seems interesting to know if there are any significant cardiac changes during official bouts. Fifteen amateur boxers, participating in the semifinals of the Italian Championship were investigated by Bianco et al.</FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial"> </FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial">A standard ECG before, immediately after, 1 hour and 12 hours after the match were obtained from each athlete to analyze:</FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial"> </FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial">1) Atrio-ventricular conduction;</FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial"> </FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial">2) QRS axis and duration;</FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial"> </FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial">3) Ventricular repolarization.</FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial"> </FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial">A blood sample was also obtained before and 12 hours after the match for analysis of total-creatin-phosphokinase, myoglobin, and T-troponin. After the fight, the following significant changes were encountered:</FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial"> </FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial">1) Higher QRS voltages;</FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial"> </FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial">2) Lowering of J-point and ST segment in lateral leads;</FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial"> </FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial">3) Higher ST-slope;</FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial"> </FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial">4) Lower T-wave amplitude;</FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial"> </FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial">5) Shorter T-wave peak time, and</FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial"> </FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial">6) Shorter QT interval.</FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial"> </FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial">When the last 2 parameters were corrected for heart rate, no differences were observed for QTc, while T-wave peak time significantly increased. All these changes persisted until one hour after the match. Moreover, 3/15 boxers (20 %) showed marked ventricular repolarization anomalies in lateral leads after the contest, persisting for 12 hours in one case. However, no athlete had clinical and humoral signs of myocardial damage following the match. It was concluded that no clinical and humoral signs of myocardial damage were found after amateur boxing matches, although ventricular repolarization abnormalities can be found on ECG in 20 % of boxers, probably due to sympathetic hyper-activity related to the agonistic event(4).</FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial"> </FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial"> </FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial"> </FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial">References</FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial">1) Koehler SA, Shakir A, Ladham S, et. al. Cardiac concussion: definition, differential diagnosis, and cases presentation and the legal ramification of a misdiagnosis. Am J Forensic Med Pathol. 2004;25:205-208.</FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial">2) Eckart RE, Scoville SL, Shry EA, Potter RN, Tedrow U. Causes of sudden death in young female military recruits.Am J Cardiol. 2006; 97:1756-1758.</FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial">3) Antzelevich C, Oliva A. Amplificaion of spatial dispersion of repolarization underlies sudden cardiac death associated with catecholaminergic J Intern Med. 2006;259:48-58</FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial">4) Bianco M, Colella F, Pannozzo A, Oradei A, et al. Boxing and "commotio cordis": ECG and humoral study. Int J Sports Med. 2005;26:151-157.</FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial"> </FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial">All the for all</FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial"><BR class="khtml-block-placeholder"></FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial">Andrés Ricardo Pérez Riera MD</FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial"> Chief of Electro-Vectocardiology Sector of the Discipline of Cardiology,</FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial"> ABC Faculty of Medicine (FMABC), Foundation of ABC (FUABC)</FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial"> – Santo André – São Paulo – Brazil.</FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial"> Sebastião Afonso 885 Jardim Miriam SP Brazil</FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial"> Zip Code: 04417-100</FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial"> <A href="mailto:riera@uol.com.br">riera@uol.com.br</A></FONT></DIV></DIV></DIV><FONT class="Apple-style-span" face="Arial"><BR></FONT><DIV> <DIV><FONT class="Apple-style-span" face="Arial">--</FONT></DIV><DIV><FONT class="Apple-style-span" face="Arial">Dr. Sergio Dubner</FONT></DIV><DIV><FONT class="Apple-style-span" face="Arial">President of Scientific Committee</FONT></DIV><DIV><FONT class="Apple-style-span" face="Arial"><BR></FONT></DIV><DIV><FONT class="Apple-style-span" face="Arial">Dr. Edgardo Schapachnik</FONT></DIV><DIV><FONT class="Apple-style-span" face="Arial">President of Steering Committee</FONT></DIV><DIV><FONT class="Apple-style-span" face="Arial"><BR class="khtml-block-placeholder"></FONT></DIV><DIV><FONT class="Apple-style-span" face="Arial"><BR class="khtml-block-placeholder"></FONT></DIV><FONT class="Apple-style-span" face="Arial"><BR class="Apple-interchange-newline"> </FONT></DIV><FONT class="Apple-style-span" face="Arial" size="3"><SPAN class="Apple-style-span" style="font-size: 13px;"><BR></SPAN></FONT></DIV></BODY></HTML>