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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Systolic anterior motion &#40;SAM&#41; is due to partial obstruction of the left ventricular outflow tract &#40;LVOT&#41; by the mitral valve &#40;MV&#41; anterior leaflet&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It has been reported in patients with hypertrophic cardiomyopathy&#44; following myocardial infarction&#44; and as a postoperative complication of MV repair&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">We describe the case of a 71-year-old female patient&#44; Caucasian&#44; admitted to our department for decompensated heart failure &#40;NYHA class III&#47;IV&#41;&#46; Her personal history included hypertension&#44; dyslipidemia&#44; chronic atrial fibrillation&#44; severe mitral regurgitation &#40;posterior leaflet prolapse&#41; and moderate to severe tricuspid regurgitation&#44; with pulmonary hypertension&#46; She had undergone cardiothoracic surgery 15 days before&#44; with mitral valve repair &#40;quadrangular resection of the posterior leaflet with implantation of a Carpentier ring&#41; and tricuspid annuloplasty&#46; Postoperative transesophageal echocardiography &#40;TEE&#41; showed good mitral valve competence and no regurgitation&#44; and no other significant alterations&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient was medicated with furosemide &#40;40&#43;20<span class="elsevierStyleHsp" style=""></span>mg&#41;&#44; enalapril 5<span class="elsevierStyleHsp" style=""></span>mg once a day&#44; carvedilol 6&#46;25<span class="elsevierStyleHsp" style=""></span>mg twice a day&#44; amiodarone 200<span class="elsevierStyleHsp" style=""></span>mg once a day&#44; spironolactone 25<span class="elsevierStyleHsp" style=""></span>mg once a day&#44; potassium chloride &#40;Retard&#41; once a day&#44; warfarin &#40;for INR 2&#8211;3&#41;&#44; omeprazole 20<span class="elsevierStyleHsp" style=""></span>mg once a day and sertraline 50<span class="elsevierStyleHsp" style=""></span>mg once a day&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">On admission to the emergency department&#44; the patient complained of precordial discomfort and worsening dyspnea on minimal exertion&#44; as well as paroxysmal nocturnal orthopnea and dyspnea&#46; Physical examination showed blood pressure of 86&#47;64<span class="elsevierStyleHsp" style=""></span>mmHg and mean heart rate &#40;HR&#41; of 150<span class="elsevierStyleHsp" style=""></span>bpm&#59; cardiac auscultation revealed arrhythmia and a grade III&#47;VI systolic murmur over the aorta&#46; Pulmonary auscultation revealed absence of breath sounds in the left lung base&#46; There was no lower limb edema&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Laboratory tests showed normocytic and normochromic anemia &#40;Hb 10&#46;9<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#41; and worsening baseline renal function &#40;urea 146<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#59; creatinine 1&#46;9<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#59; creatinine clearance &#91;by the MDRD formula&#93; 27&#46;69<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#41;&#46; The ECG revealed atrial fibrillation with mean ventricular response of 150<span class="elsevierStyleHsp" style=""></span>bpm and poor R-wave progression in V1&#8211;V2&#46; The chest X-ray showed cardiomegaly and moderate left pleural effusion&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The patient was admitted for decompensated heart failure&#46; Transthoracic echocardiography &#40;TTE&#41; performed on the first day of hospitalization &#40;with HR 120&#8211;150<span class="elsevierStyleHsp" style=""></span>bpm&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41; revealed aortic valve fibrosis with no restriction of opening&#44; together with mild regurgitation&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The MV presented fibrocalcification&#44; with increased echogenicity of the annulus&#59; the anterior leaflet and subvalvular apparatus were obstructing the LVOT&#44; resulting in an intraventricular gradient of 110<span class="elsevierStyleHsp" style=""></span>mmHg and moderate paroxysmal regurgitation &#40;probably related to the intermittent nature of the LVOT obstruction&#41;&#46; The left atrium was severely dilated &#40;6&#46;1<span class="elsevierStyleHsp" style=""></span>cm&#41;&#44; and the left ventricle was hypertrophied &#40;diastolic diameter 4&#46;3<span class="elsevierStyleHsp" style=""></span>cm&#41; but with good global systolic function&#46; The right chambers were of normal size&#44; with pulmonary artery pressure estimated at 40<span class="elsevierStyleHsp" style=""></span>mmHg&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">For a more accurate assessment of MV function&#44; TEE was performed &#40;with HR 120&#8211;150<span class="elsevierStyleHsp" style=""></span>bpm&#41; &#40;<a class="elsevierStyleCrossRefs" href="#fig0010">Figures 2 and 3</a>&#41;&#44; which showed the MV with a Carpentier ring and leaflet degeneration and redundancy&#44; good opening in diastole but with SAM leading to LVOT obstruction by the anterior leaflet&#44; and severe regurgitation &#40;vena contracta 8<span class="elsevierStyleHsp" style=""></span>mm&#41;&#46; The aortic valve was tricuspid&#44; with good opening and mild regurgitation&#46; The left atrial appendage was free of thrombi&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Since the patient&#39;s clinical condition was extremely unstable during hospital stay&#44; systolic blood pressure remaining below 90<span class="elsevierStyleHsp" style=""></span>mmHg and with clear signs of heart failure in NYHA class IV&#44; the patient was transferred to a surgical center 14 days after admission to be evaluated for surgical reintervention&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Six weeks after her initial admission to our department&#44; the patient was seen at the outpatient clinic&#59; she was hemodynamically stable&#44; in good general health and with no signs of heart failure&#46; The report from the surgical center&#44; where she had remained for three weeks&#44; revealed that surgical reintervention had not been necessary&#46; TTE at discharge showed significant improvement in echocardiographic parameters &#40;mild mitral regurgitation and no LVOT obstruction by the mitral anterior leaflet&#41;&#46; Repeat TTE a week after reassessment&#44; with optimized HR&#44; revealed good MV function &#40;mild regurgitation&#41;&#44; with no LVOT obstruction &#40;<a class="elsevierStyleCrossRefs" href="#fig0020">Figures 4 and 5</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Pathophysiology of SAM</span><p id="par0055" class="elsevierStylePara elsevierViewall">The literature indicates that SAM&#44; which has been reported after mitral valve repair in various studies&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> is caused by the velocity of the blood flow drawing the ventricular surface of the MV anterior leaflet into the LVOT&#46; The position and any abnormalities of the two leaflets contribute to the phenomenon&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Firstly&#44; the distance between the MV coaptation point and the septum is shortened due to elongation of the posterior or anterior leaflets during surgical repair&#44; increasing the area of the anterior leaflet exposed to LVOT flow&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Secondly&#44; during surgical repair of the papillary muscles&#44; the MV may be displaced anteriorly around the LVOT&#44; thus directly exposing the anterior leaflet to the outflow stream&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#8211;7</span></a> Fluid overload in the pre- and postoperative period causes the septum to bulge leftwards and restrict the LVOT&#44; while postoperative hypovolemia reduces left ventricular diastolic dimensions&#44; thus decreasing LVOT diameter&#46; All these pathophysiological conditions contribute to the development of SAM following mitral valve repair&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">However&#44; there is some debate as to how and why the MV anterior leaflet is pushed towards the LVOT once the above-mentioned conditions are present&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#8211;12</span></a> One theory is that it is due to a Venturi effect&#44; the result of a fall in pressure distally to an obstruction&#46; Pressure can be restored if there is dilatation distally to the stenosis with an angle of no more than 15&#176;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The abrupt drop in pressure before the obstruction leads to the MV being sucked towards the LVOT&#46; However&#44; studies have measured the angle of MV leaflets at the point of coaptation and reported a mean of 21&#176;&#44; which goes against the above theory&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Another mechanism proposed to explain this phenomenon is flow drag&#44; which has been likened to an open door in a corridor subjected to strong gusts of wind&#46; The stronger air flow in the middle of the corridor pushes the door in the direction of the air flow&#44; exerting pressure on an increasing area of the door until it finally slams shut&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Applying this analogy to the MV&#44; it is possible that the flow drag of blood passing the anterior leaflet pulls it towards the LVOT and causes obstruction&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Other studies have proposed a combined mechanism&#44; in which a Venturi effect lifts the leaflet towards the septum&#44; while flow drag pulls the leaflet through it&#44; closing the LVOT&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Diagnosis of SAM</span><p id="par0085" class="elsevierStylePara elsevierViewall">Echocardiography&#44; whether transesophageal or transthoracic&#44; is essential to a diagnosis of SAM&#44; as it reveals any residual parts of the MV that extend beyond the point of coaptation after valve repair and protrude into the middle of the LVOT&#44; as well as showing a reduction in ventricular dimensions and&#47;or septal bulging&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In certain types of valve repair&#44; the point of coaptation will be next to the septum&#46; Patients with documented SAM can present with dyspnea&#44; angina&#44; palpitations&#44; heart failure&#44; syncope or arrhythmias&#44; or a combination of symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Management and treatment of SAM&#58; is surgical reintervention necessary&#63;</span><p id="par0090" class="elsevierStylePara elsevierViewall">There is uncertainty regarding the natural history and management of patients with SAM after MV repair&#46; The degree of SAM extends along a spectrum from minor repercussions in the MV to its most severe form with LVOT obstruction&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Despite numerous descriptions of preventative techniques&#44; it continues to occur&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#8211;21</span></a> Management of SAM by surgical means remains controversial&#44; some groups advocating non-surgical treatment<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#44;23</span></a> and others direct surgical correction&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#8211;26</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Both hypervolemia and hypovolemia can trigger SAM&#46; Thus&#44; a patient who has undergone MV repair may initially have normal TEE&#46; Most patients undergoing cardiac surgery have hypovolemia&#44; which plays a central role in the development of hyperdynamic SAM since the Venturi effect is more marked&#44; resulting in decreased systolic volume and blood pressure&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> However&#44; SAM can also occur in hypervolemic states&#46; Increased right ventricular volume&#44; which raises pulmonary pressure&#44; causes the interventricular septum to bulge leftwards&#44; narrowing the LVOT&#46; In this situation&#44; intravenous nitrates should be considered for immediate reduction of pulmonary pressure&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Management of patients with SAM in the immediate postoperative period consists of keeping the left ventricle expanded to allow reasonable LVOT opening&#44; for which crystalloid and colloid solutions are essential&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Heart rate should be stabilized to maximize diastolic time&#46; Tachyarrhythmias reduce ventricular filling time and affect end-diastolic volume and so beta-blockers are the first-choice drug in this context&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;16</span></a> Continuous infusion is recommended rather than a bolus&#44; since the former is easier to titrate to reduce HR with the least effect on blood pressure&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Positive inotropes such as epinephrine&#44; which increase HR and contractility&#44; should be used with caution in these patients<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> since they have an adverse effect on left ventricular diastolic time&#44; resulting in a hyperdynamic state and LVOT narrowing&#44; thus increasing the severity of SAM&#46; The overall aim of medical treatment is to maintain optimal left ventricular volume&#44; which means that therapies that reduce peripheral vascular resistance should be avoided&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Since SAM can be transient or persistent&#44; treatment should be based on the severity of symptoms&#46; If these are disabling or progressively worsen&#44; surgical reintervention is recommended&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> the type of correction depending on the original surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Brown et al&#46; carried out a major retrospective study of all patients between January 1993 and December 2002 in the Division of Cardiovascular Surgery of the Mayo Clinic in whom SAM occurred during the intraoperative period&#44; and who were subsequently followed up&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> MV repair was performed in 2076 patients&#44; in 174 &#40;8&#46;4&#37;&#41; of whom SAM was detected by intraoperative echocardiography&#46; These patients were initially treated with a combination of beta-blockade&#44; vasoconstriction with phenylephrine and&#47;or intravascular volume expansion&#59; four underwent surgical repair because of persistent SAM and three underwent late surgical reintervention because of mitral regurgitation from other causes&#46; The median follow-up of the remaining 167 patients was 5&#46;4 years&#46; There were two other late reoperations&#44; but neither was due to SAM or LVOT obstruction&#46; Around 90&#37; of patients were in NYHA class I&#44; 7&#37; in class II and 3&#37; in class III or IV&#46; Echocardiograms were available for review in 93 patients&#44; of whom 13 had SAM and four had SAM with LVOT obstruction&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The above study&#39;s conclusions emphasized the fact that most cases of SAM were resolved with conservative treatment &#40;beta-blockade&#44; vasoconstriction and administration of fluids&#41;&#46; Persistent SAM with LVOT obstruction was documented in 2&#46;3&#37; of patients but did not require late reintervention&#46; The outcomes in this series &#40;no mortality and 90&#37; of patients in NYHA class I at late follow-up&#41; support a strategy of non-surgical treatment of SAM&#44; with or without LVOT obstruction&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions</span><p id="par0125" class="elsevierStylePara elsevierViewall">The review of the literature carried out in order to answer the questions raised by our case led to the conclusion that late surgical reintervention is rarely required to treat SAM with LVOT obstruction following mitral valve repair&#44; since it improves with optimized therapy and ventricular remodeling in the long term&#46; Nevertheless&#44; patients with SAM after MV repair need regular follow-up&#44; beta-blockade and avoidance of afterload-reducing medications&#46; Lifelong beta-blocker therapy is not generally required&#59; if LVOT obstruction resolves&#44; the dose can be titrated based on three-monthly echocardiographic study&#44; and if no LVOT obstruction is detected&#44; the patient can be reassessed at longer intervals&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">SAM is an important cause of mitral regurgitation early after MV repair&#44; but optimized medical therapy can preclude the need for surgical reintervention&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">The phenomenon occurs with a variety of surgical techniques&#44; and no ring or band&#44; rigid or flexible&#44; appears to have a direct influence on the outcome&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">To summarize&#44; studies support a non-surgical approach to SAM&#44; with or without LVOT obstruction&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors declare they have no conflicts of interest&#46;</p></span></span>"
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          "identificador" => "sec0015"
          "titulo" => "Pathophysiology of SAM"
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          "identificador" => "sec0020"
          "titulo" => "Diagnosis of SAM"
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        8 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Management and treatment of SAM&#58; is surgical reintervention necessary&#63;"
        ]
        9 => array:2 [
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          "titulo" => "Conclusions"
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    "fechaRecibido" => "2010-02-17"
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        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Systolic anterior motion &#40;SAM&#41; is a postoperative complication of mitral valve repair&#44; with an incidence of 5&#8211;10&#37;&#46; Early recognition of the signs and symptoms of SAM is essential for the management of these patients&#46; This article focuses on the pathophysiology and dynamics of SAM and the treatment strategies described in the literature&#46; The authors present a case study and echocardiographic images illustrating the clinical relevance of the mechanism involved&#44; in order to clarify whether surgical reintervention is necessary&#46;</p>"
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        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">O movimento anterior sist&#243;lico &#40;SAM&#41; &#233; uma complica&#231;&#227;o p&#243;s cir&#250;rgica da valvuloplastia mitral&#44; sendo a sua incid&#234;ncia de 5-10&#37;&#46; O reconhecimento precoce dos sinais e sintomas de SAM &#233; imperativo no delinear de estrat&#233;gia terap&#234;utica nesses pacientes&#46; Este artigo foca os principais mecanismos fisiopatol&#243;gicos do SAM din&#226;mico e modalidades de tratamento descritas na literatura&#46; Os autores descrevem um caso cl&#237;nico e as imagens ecocardiogr&#225;ficas captadas ilustrando a relev&#226;ncia cl&#237;nica do mecanismo envolvido&#44; na tentativa de esclarecer uma quest&#227;o suscitada&#58; reinterven&#231;&#227;o cir&#250;rgica necess&#225;ria&#63;</p>"
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        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Rodrigues&#44; B&#46; Obstru&#231;&#227;o severa do tracto de sa&#237;da do ventr&#237;culo esquerdo como complica&#231;&#227;o de valvuloplastia mitral&#58; a prop&#243;sito de um caso cl&#237;nico&#46; Rev Port Cardiol&#46; 2011&#59;<span class="elsevierStyleBold">30&#40;11&#41;</span>&#58;837&#8211;843&#46;</p>"
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Case report
Severe left ventricular outflow tract obstruction as a complication of mitral valve repair: Case report
Obstrução severa do tracto de saída do ventrículo esquerdo como complicação de valvuloplastia mitral: a propósito de um caso clínico
Bruno Rodrigues
Corresponding author
onurb80@sapo.pt

Corresponding author.
, Luís Ferreira Santos, Emanuel Correia, Rita Faria, Davide Moreira, Pedro Gama, Costa Cabral, João Pipa, Oliveira Santos
Serviço de Cardiologia, Hospital São Teotónio, Viseu, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Systolic anterior motion &#40;SAM&#41; is due to partial obstruction of the left ventricular outflow tract &#40;LVOT&#41; by the mitral valve &#40;MV&#41; anterior leaflet&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It has been reported in patients with hypertrophic cardiomyopathy&#44; following myocardial infarction&#44; and as a postoperative complication of MV repair&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">We describe the case of a 71-year-old female patient&#44; Caucasian&#44; admitted to our department for decompensated heart failure &#40;NYHA class III&#47;IV&#41;&#46; Her personal history included hypertension&#44; dyslipidemia&#44; chronic atrial fibrillation&#44; severe mitral regurgitation &#40;posterior leaflet prolapse&#41; and moderate to severe tricuspid regurgitation&#44; with pulmonary hypertension&#46; She had undergone cardiothoracic surgery 15 days before&#44; with mitral valve repair &#40;quadrangular resection of the posterior leaflet with implantation of a Carpentier ring&#41; and tricuspid annuloplasty&#46; Postoperative transesophageal echocardiography &#40;TEE&#41; showed good mitral valve competence and no regurgitation&#44; and no other significant alterations&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient was medicated with furosemide &#40;40&#43;20<span class="elsevierStyleHsp" style=""></span>mg&#41;&#44; enalapril 5<span class="elsevierStyleHsp" style=""></span>mg once a day&#44; carvedilol 6&#46;25<span class="elsevierStyleHsp" style=""></span>mg twice a day&#44; amiodarone 200<span class="elsevierStyleHsp" style=""></span>mg once a day&#44; spironolactone 25<span class="elsevierStyleHsp" style=""></span>mg once a day&#44; potassium chloride &#40;Retard&#41; once a day&#44; warfarin &#40;for INR 2&#8211;3&#41;&#44; omeprazole 20<span class="elsevierStyleHsp" style=""></span>mg once a day and sertraline 50<span class="elsevierStyleHsp" style=""></span>mg once a day&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">On admission to the emergency department&#44; the patient complained of precordial discomfort and worsening dyspnea on minimal exertion&#44; as well as paroxysmal nocturnal orthopnea and dyspnea&#46; Physical examination showed blood pressure of 86&#47;64<span class="elsevierStyleHsp" style=""></span>mmHg and mean heart rate &#40;HR&#41; of 150<span class="elsevierStyleHsp" style=""></span>bpm&#59; cardiac auscultation revealed arrhythmia and a grade III&#47;VI systolic murmur over the aorta&#46; Pulmonary auscultation revealed absence of breath sounds in the left lung base&#46; There was no lower limb edema&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Laboratory tests showed normocytic and normochromic anemia &#40;Hb 10&#46;9<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#41; and worsening baseline renal function &#40;urea 146<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#59; creatinine 1&#46;9<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#59; creatinine clearance &#91;by the MDRD formula&#93; 27&#46;69<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#41;&#46; The ECG revealed atrial fibrillation with mean ventricular response of 150<span class="elsevierStyleHsp" style=""></span>bpm and poor R-wave progression in V1&#8211;V2&#46; The chest X-ray showed cardiomegaly and moderate left pleural effusion&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The patient was admitted for decompensated heart failure&#46; Transthoracic echocardiography &#40;TTE&#41; performed on the first day of hospitalization &#40;with HR 120&#8211;150<span class="elsevierStyleHsp" style=""></span>bpm&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41; revealed aortic valve fibrosis with no restriction of opening&#44; together with mild regurgitation&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The MV presented fibrocalcification&#44; with increased echogenicity of the annulus&#59; the anterior leaflet and subvalvular apparatus were obstructing the LVOT&#44; resulting in an intraventricular gradient of 110<span class="elsevierStyleHsp" style=""></span>mmHg and moderate paroxysmal regurgitation &#40;probably related to the intermittent nature of the LVOT obstruction&#41;&#46; The left atrium was severely dilated &#40;6&#46;1<span class="elsevierStyleHsp" style=""></span>cm&#41;&#44; and the left ventricle was hypertrophied &#40;diastolic diameter 4&#46;3<span class="elsevierStyleHsp" style=""></span>cm&#41; but with good global systolic function&#46; The right chambers were of normal size&#44; with pulmonary artery pressure estimated at 40<span class="elsevierStyleHsp" style=""></span>mmHg&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">For a more accurate assessment of MV function&#44; TEE was performed &#40;with HR 120&#8211;150<span class="elsevierStyleHsp" style=""></span>bpm&#41; &#40;<a class="elsevierStyleCrossRefs" href="#fig0010">Figures 2 and 3</a>&#41;&#44; which showed the MV with a Carpentier ring and leaflet degeneration and redundancy&#44; good opening in diastole but with SAM leading to LVOT obstruction by the anterior leaflet&#44; and severe regurgitation &#40;vena contracta 8<span class="elsevierStyleHsp" style=""></span>mm&#41;&#46; The aortic valve was tricuspid&#44; with good opening and mild regurgitation&#46; The left atrial appendage was free of thrombi&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Since the patient&#39;s clinical condition was extremely unstable during hospital stay&#44; systolic blood pressure remaining below 90<span class="elsevierStyleHsp" style=""></span>mmHg and with clear signs of heart failure in NYHA class IV&#44; the patient was transferred to a surgical center 14 days after admission to be evaluated for surgical reintervention&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Six weeks after her initial admission to our department&#44; the patient was seen at the outpatient clinic&#59; she was hemodynamically stable&#44; in good general health and with no signs of heart failure&#46; The report from the surgical center&#44; where she had remained for three weeks&#44; revealed that surgical reintervention had not been necessary&#46; TTE at discharge showed significant improvement in echocardiographic parameters &#40;mild mitral regurgitation and no LVOT obstruction by the mitral anterior leaflet&#41;&#46; Repeat TTE a week after reassessment&#44; with optimized HR&#44; revealed good MV function &#40;mild regurgitation&#41;&#44; with no LVOT obstruction &#40;<a class="elsevierStyleCrossRefs" href="#fig0020">Figures 4 and 5</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Pathophysiology of SAM</span><p id="par0055" class="elsevierStylePara elsevierViewall">The literature indicates that SAM&#44; which has been reported after mitral valve repair in various studies&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> is caused by the velocity of the blood flow drawing the ventricular surface of the MV anterior leaflet into the LVOT&#46; The position and any abnormalities of the two leaflets contribute to the phenomenon&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Firstly&#44; the distance between the MV coaptation point and the septum is shortened due to elongation of the posterior or anterior leaflets during surgical repair&#44; increasing the area of the anterior leaflet exposed to LVOT flow&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Secondly&#44; during surgical repair of the papillary muscles&#44; the MV may be displaced anteriorly around the LVOT&#44; thus directly exposing the anterior leaflet to the outflow stream&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#8211;7</span></a> Fluid overload in the pre- and postoperative period causes the septum to bulge leftwards and restrict the LVOT&#44; while postoperative hypovolemia reduces left ventricular diastolic dimensions&#44; thus decreasing LVOT diameter&#46; All these pathophysiological conditions contribute to the development of SAM following mitral valve repair&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">However&#44; there is some debate as to how and why the MV anterior leaflet is pushed towards the LVOT once the above-mentioned conditions are present&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#8211;12</span></a> One theory is that it is due to a Venturi effect&#44; the result of a fall in pressure distally to an obstruction&#46; Pressure can be restored if there is dilatation distally to the stenosis with an angle of no more than 15&#176;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The abrupt drop in pressure before the obstruction leads to the MV being sucked towards the LVOT&#46; However&#44; studies have measured the angle of MV leaflets at the point of coaptation and reported a mean of 21&#176;&#44; which goes against the above theory&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Another mechanism proposed to explain this phenomenon is flow drag&#44; which has been likened to an open door in a corridor subjected to strong gusts of wind&#46; The stronger air flow in the middle of the corridor pushes the door in the direction of the air flow&#44; exerting pressure on an increasing area of the door until it finally slams shut&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Applying this analogy to the MV&#44; it is possible that the flow drag of blood passing the anterior leaflet pulls it towards the LVOT and causes obstruction&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Other studies have proposed a combined mechanism&#44; in which a Venturi effect lifts the leaflet towards the septum&#44; while flow drag pulls the leaflet through it&#44; closing the LVOT&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Diagnosis of SAM</span><p id="par0085" class="elsevierStylePara elsevierViewall">Echocardiography&#44; whether transesophageal or transthoracic&#44; is essential to a diagnosis of SAM&#44; as it reveals any residual parts of the MV that extend beyond the point of coaptation after valve repair and protrude into the middle of the LVOT&#44; as well as showing a reduction in ventricular dimensions and&#47;or septal bulging&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In certain types of valve repair&#44; the point of coaptation will be next to the septum&#46; Patients with documented SAM can present with dyspnea&#44; angina&#44; palpitations&#44; heart failure&#44; syncope or arrhythmias&#44; or a combination of symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Management and treatment of SAM&#58; is surgical reintervention necessary&#63;</span><p id="par0090" class="elsevierStylePara elsevierViewall">There is uncertainty regarding the natural history and management of patients with SAM after MV repair&#46; The degree of SAM extends along a spectrum from minor repercussions in the MV to its most severe form with LVOT obstruction&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Despite numerous descriptions of preventative techniques&#44; it continues to occur&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#8211;21</span></a> Management of SAM by surgical means remains controversial&#44; some groups advocating non-surgical treatment<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#44;23</span></a> and others direct surgical correction&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#8211;26</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Both hypervolemia and hypovolemia can trigger SAM&#46; Thus&#44; a patient who has undergone MV repair may initially have normal TEE&#46; Most patients undergoing cardiac surgery have hypovolemia&#44; which plays a central role in the development of hyperdynamic SAM since the Venturi effect is more marked&#44; resulting in decreased systolic volume and blood pressure&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> However&#44; SAM can also occur in hypervolemic states&#46; Increased right ventricular volume&#44; which raises pulmonary pressure&#44; causes the interventricular septum to bulge leftwards&#44; narrowing the LVOT&#46; In this situation&#44; intravenous nitrates should be considered for immediate reduction of pulmonary pressure&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Management of patients with SAM in the immediate postoperative period consists of keeping the left ventricle expanded to allow reasonable LVOT opening&#44; for which crystalloid and colloid solutions are essential&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Heart rate should be stabilized to maximize diastolic time&#46; Tachyarrhythmias reduce ventricular filling time and affect end-diastolic volume and so beta-blockers are the first-choice drug in this context&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;16</span></a> Continuous infusion is recommended rather than a bolus&#44; since the former is easier to titrate to reduce HR with the least effect on blood pressure&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Positive inotropes such as epinephrine&#44; which increase HR and contractility&#44; should be used with caution in these patients<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> since they have an adverse effect on left ventricular diastolic time&#44; resulting in a hyperdynamic state and LVOT narrowing&#44; thus increasing the severity of SAM&#46; The overall aim of medical treatment is to maintain optimal left ventricular volume&#44; which means that therapies that reduce peripheral vascular resistance should be avoided&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Since SAM can be transient or persistent&#44; treatment should be based on the severity of symptoms&#46; If these are disabling or progressively worsen&#44; surgical reintervention is recommended&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> the type of correction depending on the original surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Brown et al&#46; carried out a major retrospective study of all patients between January 1993 and December 2002 in the Division of Cardiovascular Surgery of the Mayo Clinic in whom SAM occurred during the intraoperative period&#44; and who were subsequently followed up&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> MV repair was performed in 2076 patients&#44; in 174 &#40;8&#46;4&#37;&#41; of whom SAM was detected by intraoperative echocardiography&#46; These patients were initially treated with a combination of beta-blockade&#44; vasoconstriction with phenylephrine and&#47;or intravascular volume expansion&#59; four underwent surgical repair because of persistent SAM and three underwent late surgical reintervention because of mitral regurgitation from other causes&#46; The median follow-up of the remaining 167 patients was 5&#46;4 years&#46; There were two other late reoperations&#44; but neither was due to SAM or LVOT obstruction&#46; Around 90&#37; of patients were in NYHA class I&#44; 7&#37; in class II and 3&#37; in class III or IV&#46; Echocardiograms were available for review in 93 patients&#44; of whom 13 had SAM and four had SAM with LVOT obstruction&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The above study&#39;s conclusions emphasized the fact that most cases of SAM were resolved with conservative treatment &#40;beta-blockade&#44; vasoconstriction and administration of fluids&#41;&#46; Persistent SAM with LVOT obstruction was documented in 2&#46;3&#37; of patients but did not require late reintervention&#46; The outcomes in this series &#40;no mortality and 90&#37; of patients in NYHA class I at late follow-up&#41; support a strategy of non-surgical treatment of SAM&#44; with or without LVOT obstruction&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions</span><p id="par0125" class="elsevierStylePara elsevierViewall">The review of the literature carried out in order to answer the questions raised by our case led to the conclusion that late surgical reintervention is rarely required to treat SAM with LVOT obstruction following mitral valve repair&#44; since it improves with optimized therapy and ventricular remodeling in the long term&#46; Nevertheless&#44; patients with SAM after MV repair need regular follow-up&#44; beta-blockade and avoidance of afterload-reducing medications&#46; Lifelong beta-blocker therapy is not generally required&#59; if LVOT obstruction resolves&#44; the dose can be titrated based on three-monthly echocardiographic study&#44; and if no LVOT obstruction is detected&#44; the patient can be reassessed at longer intervals&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">SAM is an important cause of mitral regurgitation early after MV repair&#44; but optimized medical therapy can preclude the need for surgical reintervention&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">The phenomenon occurs with a variety of surgical techniques&#44; and no ring or band&#44; rigid or flexible&#44; appears to have a direct influence on the outcome&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">To summarize&#44; studies support a non-surgical approach to SAM&#44; with or without LVOT obstruction&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors declare they have no conflicts of interest&#46;</p></span></span>"
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          "identificador" => "sec0015"
          "titulo" => "Pathophysiology of SAM"
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          "identificador" => "sec0020"
          "titulo" => "Diagnosis of SAM"
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        8 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Management and treatment of SAM&#58; is surgical reintervention necessary&#63;"
        ]
        9 => array:2 [
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          "titulo" => "Conclusions"
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    "fechaRecibido" => "2010-02-17"
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        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Systolic anterior motion &#40;SAM&#41; is a postoperative complication of mitral valve repair&#44; with an incidence of 5&#8211;10&#37;&#46; Early recognition of the signs and symptoms of SAM is essential for the management of these patients&#46; This article focuses on the pathophysiology and dynamics of SAM and the treatment strategies described in the literature&#46; The authors present a case study and echocardiographic images illustrating the clinical relevance of the mechanism involved&#44; in order to clarify whether surgical reintervention is necessary&#46;</p>"
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        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">O movimento anterior sist&#243;lico &#40;SAM&#41; &#233; uma complica&#231;&#227;o p&#243;s cir&#250;rgica da valvuloplastia mitral&#44; sendo a sua incid&#234;ncia de 5-10&#37;&#46; O reconhecimento precoce dos sinais e sintomas de SAM &#233; imperativo no delinear de estrat&#233;gia terap&#234;utica nesses pacientes&#46; Este artigo foca os principais mecanismos fisiopatol&#243;gicos do SAM din&#226;mico e modalidades de tratamento descritas na literatura&#46; Os autores descrevem um caso cl&#237;nico e as imagens ecocardiogr&#225;ficas captadas ilustrando a relev&#226;ncia cl&#237;nica do mecanismo envolvido&#44; na tentativa de esclarecer uma quest&#227;o suscitada&#58; reinterven&#231;&#227;o cir&#250;rgica necess&#225;ria&#63;</p>"
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        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Rodrigues&#44; B&#46; Obstru&#231;&#227;o severa do tracto de sa&#237;da do ventr&#237;culo esquerdo como complica&#231;&#227;o de valvuloplastia mitral&#58; a prop&#243;sito de um caso cl&#237;nico&#46; Rev Port Cardiol&#46; 2011&#59;<span class="elsevierStyleBold">30&#40;11&#41;</span>&#58;837&#8211;843&#46;</p>"
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Article information
ISSN: 21742049
Original language: English
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2023 July 79 28 107
2023 June 79 22 101
2023 May 100 37 137
2023 April 57 9 66
2023 March 61 19 80
2023 February 67 26 93
2023 January 68 13 81
2022 December 58 23 81
2022 November 102 33 135
2022 October 56 22 78
2022 September 56 52 108
2022 August 60 47 107
2022 July 66 35 101
2022 June 62 24 86
2022 May 51 30 81
2022 April 63 35 98
2022 March 44 38 82
2022 February 60 24 84
2022 January 77 22 99
2021 December 46 41 87
2021 November 65 38 103
2021 October 80 55 135
2021 September 72 43 115
2021 August 102 71 173
2021 July 38 36 74
2021 June 51 20 71
2021 May 68 39 107
2021 April 109 40 149
2021 March 93 26 119
2021 February 112 26 138
2021 January 72 28 100
2020 December 73 30 103
2020 November 87 26 113
2020 October 85 24 109
2020 September 112 20 132
2020 August 68 27 95
2020 July 118 15 133
2020 June 93 19 112
2020 May 113 15 128
2020 April 94 27 121
2020 March 130 32 162
2020 February 209 29 238
2020 January 81 16 97
2019 December 83 12 95
2019 November 51 9 60
2019 October 81 17 98
2019 September 150 26 176
2019 August 87 11 98
2019 July 161 20 181
2019 June 127 29 156
2019 May 80 28 108
2019 April 82 30 112
2019 March 110 16 126
2019 February 133 26 159
2019 January 120 22 142
2018 December 146 22 168
2018 November 123 20 143
2018 October 259 32 291
2018 September 62 11 73
2018 August 87 24 111
2018 July 52 7 59
2018 June 55 6 61
2018 May 58 13 71
2018 April 125 10 135
2018 March 104 19 123
2018 February 64 19 83
2018 January 47 23 70
2017 December 58 16 74
2017 November 55 16 71
2017 October 78 16 94
2017 September 93 14 107
2017 August 74 20 94
2017 July 58 13 71
2017 June 75 17 92
2017 May 144 13 157
2017 April 84 10 94
2017 March 88 8 96
2017 February 136 8 144
2017 January 102 8 110
2016 December 101 33 134
2016 November 189 12 201
2016 October 163 28 191
2016 September 108 10 118
2016 August 42 4 46
2016 July 43 11 54
2016 June 29 4 33
2016 May 44 5 49
2016 April 159 2 161
2016 March 268 25 293
2016 February 272 34 306
2016 January 235 26 261
2015 December 211 23 234
2015 November 270 18 288
2015 October 238 19 257
2015 September 215 14 229
2015 August 224 13 237
2015 July 308 13 321
2015 June 199 8 207
2015 May 211 7 218
2015 April 225 19 244
2015 March 224 9 233
2015 February 188 11 199
2015 January 134 9 143
2014 December 169 15 184
2014 November 197 13 210
2014 October 244 8 252
2014 September 222 19 241
2014 August 194 6 200
2014 July 201 14 215
2014 June 159 8 167
2014 May 170 14 184
2014 April 191 12 203
2014 March 204 23 227
2014 February 200 11 211
2014 January 221 24 245
2013 December 184 14 198
2013 November 157 19 176
2013 October 170 18 188
2013 September 169 17 186
2013 August 139 25 164
2013 July 191 23 214
2013 June 113 16 129
2013 May 117 18 135
2013 April 110 25 135
2013 March 118 20 138
2013 February 93 21 114
2013 January 115 20 135
2012 December 86 16 102
2012 November 74 24 98
2012 October 61 11 72
2012 September 33 5 38
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