The Damar Hamlin dilemma: What to do about commotio cordis?

Rob Vito has built a reputation as a smooth salesman since he began making military-grade protective gear for athletes more than a decade ago.

He once had someone smash a Louisville Slugger across his chest to prove his confidence in one of his products.

He personally guaranteed that Michael Vick wouldn’t aggravate his bruised ribs while wearing a custom-fitted protective vest.

He often casually brings up that his company has outfitted everyone from Tom Cruise to Tony Romo to the Pope.

And yet for all Vito’s marketing savvy, it isn’t a catchy slogan or publicity stunt that did the most to elevate his company’s stature. Unequal Technologies attracted a horde of new customers the past few months because of Damar Hamlin’s near-fatal collapse during a Monday Night Football game last January.

When a national TV audience watched Hamlin go into sudden cardiac arrest on the field after making a seemingly routine tackle, viewers scrambled to better understand what happened to the Buffalo Bills safety. Medical experts quickly suggested that a lowered shoulder to the chest from Cincinnati Bengals receiver Tee Higgins may have caused Hamlin, 25, to experience a rare but often lethal heart disruption known as commotio cordis.

It was at that point, Vito says, that the threat of commotio cordis “became real” for the layperson. Parents who sought to protect their kids from what happened to Hamlin hunted for gear created to reduce the risk of commotio cordis and purchased chest protectors and padded shirts from Unequal and other manufacturers. Several NFL team owners even contacted Vito to learn more.

“Our sales went up about 800% almost overnight,” Vito told Yahoo Sports. “We were running to UPS and FedEx in the afternoons until about 8 p.m. at night. It was nonstop around the clock six, seven days a week trying to get all the product out to satisfy the need.”

Last week, Hamlin confirmed for the first time that commotio cordis indeed was what caused his heart to stop beating. He’s only alive and functioning normally today because medical personnel on site were able to administer CPR to restore the flow of blood to his vital organs before using an automatic external defibrillator to shock his heart back into rhythm.

Hamlin’s story has shined a spotlight on a condition that is among the most common causes of sudden cardiac death in competitive sports. Cardiologists say that approximately 10 to 20 cases occur annually and that teenage boys are the most vulnerable. Commotio cordis is seen most often in baseball, lacrosse and hockey, all sports where it’s common for an athlete to take a solid hard ball to the chest. In other sports, commotio cordis can be triggered by the impact of an elbow, fist or helmet.

While the prompt and effective response of the Bills medical staff saved Hamlin, most athletes don’t have access to the NFL’s vast resources and well-drilled emergency personnel. It raises the question whether commotio cordis protective gear should be more prevalent — or even required — in certain sports.

“If there’s something out there that can protect our kids from dying of sudden cardiac arrest, why aren’t we using it?” said Maureen Legg of Parent Heart Watch. “We have the tools we need to start saving lives. We just need to use them.”

Death on the field

Louis Acompora awoke with nervous anticipation on the morning of March 25, 2000. Later that day was his first high school lacrosse game, a major milestone for a 14-year-old freshman who began carrying a lacrosse stick under his arm soon after he learned how to walk.

Early in the second quarter, Acompora used his chest to block an opposing player’s routine shot from distance. The teenage goalie took a couple steps forward to scoop up the ball. Then, out of nowhere, he collapsed.

At first, John and Karen Acompora didn’t even leave the stands to check on their son because they assumed he tripped or got the wind knocked out of him. Only after Louis didn’t get up did his parents realize something was dreadfully wrong.

For Karen Acompora, the next few minutes are a nightmarish blur. She recalls the coaches and athletic trainers rushing out and yelling that Louis didn’t have a pulse. They then administered CPR in hopes of maintaining the flow of blood and oxygen to Louis’ brain and other vital organs until paramedics arrived with a defibrillator.

“Unfortunately the paramedics didn’t come for almost 15 minutes,” Karen said. “Louis didn’t even have a chance at survival.”

The coroner who conducted the autopsy of Louis’ body found nothing out of the ordinary — no underlying issues, not even a bruise on his chest. He wanted to write that Louis died of “natural causes” on the death certificate, but Karen wasn’t willing to accept that explanation.

“We thought he had to have something wrong with him,” she said.

The search for answers led Karen to Mark Link, a cardiologist who had recently helped unlock the mystery of why some adolescent athletes die from relatively innocent blows to the chest from a ball or similar projectile. Link and several colleagues demonstrated that a moderate blow could stop the heart if it occurred at exactly the wrong segment of the cardiac cycle.

Link listened to Karen’s account of Louis’ death. Then he told her, “Sounds like commotio cordis to me.”

At the same time that Karen Acompora was grappling with the riddle of how her son died, the executive director of an athletic safety nonprofit was trying to assess the threat that commotio cordis presented. Mike Oliver of the National Operating Committee on Standards for Athletic Equipment wanted to figure out, “Does this happen once in 10 years? Does this happen three or four times a year? And in what sports and to what extent?”

What NOCSAE-funded research efforts revealed, Oliver said, was this was “no small thing.” There were about 10 to 20 documented cases of commotio cordis per year, almost all involving otherwise healthy teenage boys like Louis. Many of the victims went into cardiac arrest after being tackled in a football game or struck by baseballs, lacrosse balls or hockey pucks. It also occurred as a result of play-fighting with friends, a snowball to the chest or even an ill-advised attempt to terminate hiccups.

“It didn’t happen every day or every weekend, but when it did happen it was nearly universally fatal,” Oliver said. “If you didn’t have cardiac defibrillation immediately, the chance of surviving was extremely low.”

Desperate to find some good in their son’s tragic death, John and Karen Acompora partnered with NOSCAE in hopes of preventing similar future tragedies. The Louis K. Acompora Foundation’s immediate goal was to place a portable device known as an automated external defibrillator at every school, gymnasium and athletic field across New York and beyond. Had an AED been available when Louis collapsed, someone might have been able to revive him by shocking his heart back into rhythm.

The long-term goal for the Acompora family was to raise money to aid in the development of safety gear athletes could wear to prevent commotio cordis. At the time of his death, Louis was wearing a chest protector. Karen would soon come to find out that, when it came to protecting his heart, it didn’t do him a lick of good.

The quest for real protection

In the mid-2000s, with the backing of NOSCAE and the Acompora Foundation, Dr. Mark Link and a handful of colleagues began assessing the effectiveness of commercially available chest protectors at preventing commotio cordis.

Of the 12 chest protectors that they tested, none significantly decreased the occurrence of commotio cordis in juvenile pigs struck by a baseball or lacrosse ball. Even a product called the Heart Gard provided nothing more than a false sense of security.

“Wearing those chest protectors was no better than wearing no chest protector,” Link said.

Out of that eye-opening discovery came Link’s next challenge. He needed to pinpoint the exact conditions under which commotio cordis occurred. And then he needed to use that data to help NOSCAE establish a performance standard that manufacturers had to meet to prove that their safety gear would significantly reduce the risk of injury and death from commotio cordis.

Through further testing with pigs, Link determined that a confluence of certain critical variables was necessary to induce commotio cordis with a ball. The timing in the cardiac cycle was the most important. A direct hit over the center of the left ventricle was also key, as was the hardness of the ball and the pliability of the victim’s chest wall. Impact usually had to occur at least 30 miles per hour but anything faster than 50 miles per hour decreased the rate of cardiac arrest and often instead led to cardiac rupture and trauma.

At the same time as Link conducted testing with pigs, Dr. Nathan Dau worked tirelessly inside a Wayne State laboratory building a biomechanical chest surrogate that mimicked the response of the human chest and heart to testing impacts. When a baseball or lacrosse ball is shot at the surrogate at just the right speed, internal censors measure the impact force to assess whether a chest protector performs well enough to prevent commotio cordis.

“Once we know what the performance threshold is, we don’t design the safety equipment,” Oliver said. “We just say, ‘Hey, here’s the standard. Manufacturers, you’ve got all the engineers, all the expertise. You figure it out.”

For athletic equipment manufacturers, the challenge was to conceive of a product that was lightweight and comfortable for athletes yet met NOCSAE’s standard. Link said manufacturers had little choice but to experiment with harder, stiffer materials than the soft, spongy chest protectors of the previous era.

In the past five years, more than a half dozen athletic equipment manufacturers have developed commotio cordis protective gear for baseball and lacrosse that is certified as meeting NOCSAE standards. Nike, Adidas, Rawlings and Wilson are among the corporate giants with a foothold in the market. Then there are also up-and-coming companies like Unequal.

“One of the approaches by manufacturers was to design a pad that resembled a shallow dome,” Oliver said. “If the ball hit right in the middle of the cardiac silhouette, the energy transferred out to the edges of the pad beyond the cardiac silhouette.

“Another thing they realized was you probably aren’t going to be able to do it with a single type of foam. You need layers. You might have a hard external layer, a secondary layer that was a little less rigid and then a layer that was next to the body and a little more conforming.”

No sport has embraced commotio cordis safety like lacrosse. Scarred by the death of Acompora and more than a dozen other high school or college athletes, USA Lacrosse began requiring all goalies to wear NOCSAE-certified chest protection in 2021 and all boys’ and men’s field players to do the same the following year. The NFHS and NCAA followed suit and made those rule changes universal.

To Karen Acompora, it was a victory two decades in the making.

“It was like hallelujah!” she said. “It took way too long but here we are.”

The debate: Should chest protectors be mandatory?

The lingering question in the wake of Hamlin’s collapse and recovery — Hamlin has been cleared to return to team activities — is whether other sports will start to follow lacrosse’s lead regarding commotio cordis protective gear.

Could the requirement of chest protectors and padded shirts save lives? Or is that overkill given that NOCSAE-certified gear costs up to $100 an item and that commotio cordis impacts so few athletes each year?

So far the NFL doesn’t appear to be throwing its resources behind the development of shoulder pads that would extend lower on the chest to better protect the heart. Asked about the league’s plans regarding commotio cordis safety gear, an NFL spokesperson said she had no updates. She instead highlighted the league’s efforts to persuade all 50 states to prioritize emergency preparedness in order to prevent sudden cardiac arrest from having a fatal outcome.

To cardiologist Barry Maron, one of the world's foremost researchers on commotio cordis, the NFL is correct to emphasize AED availability and CPR/AED education for high school coaches. Maron considers that to be a more practical prevention tool than the widespread adoption of chest protectors and other safety gear.

“It’s the secondary prevention, the resuscitation and defibrillation,” Maron said. “The secondary prevention works.”

Link agrees that CPR education is the most critical, pointing out that “good CPR can keep the brain alive until an AED gets there.” But Link argues that paying for NOCSAE-certified chest protection is also essential for young athletes in “any sport in which you get hit in the chest all the time.”

For Link, that means baseball pitchers and catchers. Or hockey and lacrosse players. Or softball corner infielders who crash the plate to cover bunts. It doesn’t mean that a centerfielder needs a chest protector while playing in the field.

“I’m not advocating for everyone in youth sports to wear a chest protector,” Link said. “I’m not advocating for that at all. I’m saying if you take frequent hits to the chest, you should wear a good chest protector.”

The fight to protect young athletes from commotio cordis is especially personal for Karen Acompora. That’s why she’s pleased that the phenomenon has been in the national limelight for the past few months because of Hamlin. And that’s why she seethes whenever a writer or TV analyst refers to commotio cordis as “extremely rare.”

“When you write that, a parent looks at it like, ‘I don’t even have to think about that. It’s never going to happen to me,’ ” Acompora said. “But it happened to me. My child died from that. And if it happened to me, it could happen to you.”