Case report
Caseous calcification of the mitral annulus: A multi-modality imaging perspective
Degenerescência caseosa da calcificação do anel mitral: uma perspectiva multi-imagem
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"referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Cardiology Department – Braga Hospital, Braga, Portugal" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Vila Nova de Gaia/Espinho Hospital Centre, Vila Nova de Gaia, Portugal" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Degenerescência caseosa da calcificação do anel mitral: uma perspectiva multi-imagem" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0045" "etiqueta" => "Figure 9" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr9.jpeg" "Alto" => 312 "Ancho" => 787 "Tamanyo" => 34579 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Maximum intensity multislice CT projection showing a partially calcified hyperintense mass (arrow) in non-contrast acquisition (four-chamber and short-axis view).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Mitral annulus calcification is a common echocardiographic finding, particularly in the elderly and in end-stage renal disease patients under chronic dialysis.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Caseous calcification of the mitral annulus (CCMA) or liquefaction necrosis of mitral annulus calcification is a rare evolution of mitral annular calcification, with a prevalence of 0.6% in this population and of 0.06–0.07% in large series of patients of all ages.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> Early recognition of this entity avoids an invasive diagnostic approach, since it is benign and, unlike intracardiac tumors and abscesses, has a favorable prognosis.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–4,8–10</span></a> Echocardiography typically identifies this entity as a round, calcified mass with an echolucent, liquid-like inner part. The authors present the case of an 84-year-old woman with caseous calcification of the posterior mitral annulus.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">An 84-year-old woman, with a history of hypertension and dyslipidemia, was admitted to our institution because of an intracardiac mass. She described a five-month history of shortness of breath on exertion (NYHA functional class III) and peripheral edema. Physical examination revealed a grade III/VI mitral systolic murmur. The electrocardiogram was unremarkable. Laboratory tests results showed no significant alterations. The transthoracic echocardiogram demonstrated a large, round, heterogeneous, echodense mass at the base of the posterior leaflet (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Doppler examination documented severe mitral regurgitation. The three-dimensional transthoracic echocardiogram revealed the mass involving the posterior mitral annulus, distorting it into a more triangular shape (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Three-dimensional transthoracic color flow imaging showed an eccentric mitral regurgitation jet originating from the posteromedial commissure (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). The transesophageal echocardiogram confirmed the location of the mass and severe mitral regurgitation (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>), with two jets identified, one central and the other eccentric, apparently originating from the posteromedial commissure. Cardiac magnetic resonance (CMR) imaging was performed to better evaluate the mass. This showed a hypointense mass in the posterior region of the mitral annulus/basal segment of the inferior wall (<a class="elsevierStyleCrossRefs" href="#fig0025">Figs. 5 and 6</a>). Rest perfusion CMR demonstrated hypoperfusion of the mass compared to normal myocardium (<a class="elsevierStyleCrossRef" href="#fig0035">Fig. 7</a>). Phase-sensitive inversion-recovery CMR showed late gadolinium enhancement in the peripheral margin of the mass (<a class="elsevierStyleCrossRef" href="#fig0040">Fig. 8</a>). On the basis of the above findings, a presumptive diagnosis of a centrally liquefied mass containing a high-protein or hemorrhagic content with an inflammatory and/or fibrotic wall was made. A multislice computed tomography (CT) scan of the heart was also performed, demonstrating a relatively homogeneous, high-density mass with foci of calcification (<a class="elsevierStyleCrossRefs" href="#fig0045">Figs. 9 and 10</a>). A multi-modality imaging approach confirmed the diagnosis of caseous calcification of the posterior mitral annulus.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia><elsevierMultimedia ident="fig0035"></elsevierMultimedia><elsevierMultimedia ident="fig0040"></elsevierMultimedia><elsevierMultimedia ident="fig0045"></elsevierMultimedia><elsevierMultimedia ident="fig0050"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The patient refused surgery. Medical treatment was optimized.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">CCMA is a rare evolution of mitral annular calcification.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> Echocardiography typically identifies this entity as a round, calcified, echogenic mass.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> CMR reveals a mass between the posterior mitral annulus and adjacent myocardium, with no enhancement after contrast administration and with strong peripheral enhancement 10 minutes after gadolinium administration with the use of the contrast-enhanced inversion-recovery technique.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> CT confirms the calcified aspect of the mass. Histological examination of the inner fluid usually reveals an amorphous, basophilic content, composed of a putty-like admixture of fatty acids, cholesterol, calcium and inflammatory cells, mainly macrophages.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,6</span></a> Early recognition of this entity avoids an invasive diagnostic approach, since it is benign and, unlike intracardiac tumors and abscesses, has a favorable prognosis.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Surgery should be reserved for cases with severe co-existent mitral valve dysfunction, originating from compromised mitral leaflet coaptation secondary to mitral annulus distortion due to CCMA. There are brief references in the literature to possible spontaneous resolution of this entity.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9</span></a> CCMA may rarely be associated with heart rhythm disturbances and systemic embolism.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions</span><p id="par0025" class="elsevierStylePara elsevierViewall">Caseous calcification of the mitral annulus (CCMA) or liquefaction necrosis of mitral annulus calcification is a rare evolution of mitral annular calcification. Although transthoracic echocardiography can be sensitive in diagnosing this entity, the diagnosis can sometimes still be inconclusive. Multi-modality imaging with CMR or CT can lead to a definitive diagnosis, avoiding a surgical approach. Once the diagnosis is made, the patient should be treated medically and be monitored clinically and echocardiographically unless there is associated severe mitral valve dysfunction, in which case cardiac surgery is the best therapeutic option.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres176179" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec164555" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres176180" "titulo" => "Resumo" ] 3 => array:2 [ "identificador" => "xpalclavsec164556" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusions" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-08-15" "fechaAceptado" => "2011-09-15" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec164555" "palabras" => array:6 [ 0 => "Intracardiac mass" 1 => "Caseous calcification of mitral annulus" 2 => "Mitral regurgitation" 3 => "Transthoracic echocardiography" 4 => "Cardiac computed tomography" 5 => "Cardiac magnetic resonance" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec164556" "palabras" => array:6 [ 0 => "Massa intracardíaca" 1 => "Calcificação caseosa do anel mitral" 2 => "Insuficiência mitral" 3 => "Ecocardiograma transtorácico" 4 => "Angio-TC cardíaca" 5 => "Ressonância magnética cardíaca" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Mitral annulus calcification is a common echocardiographic finding, particularly in the elderly and in end-stage renal disease patients under chronic dialysis. Caseous calcification or liquefaction necrosis of mitral annulus calcification is a rare evolution of mitral annular calcification. Early recognition of this entity avoids an invasive diagnostic approach, since it is benign and, unlike intracardiac tumors and abscesses, has a favorable prognosis. The authors present the case of an 84-year-old woman with a suspicious large, echodense mass at the level of the posterior mitral leaflet with associated severe mitral regurgitation. Cardiac magnetic resonance imaging demonstrated a hypoperfused mass with strong peripheral enhancement 10 minutes after gadolinium administration. Multislice computed tomography showed the calcified nature of the mass. A multi-modality imaging approach confirmed the diagnosis of caseous calcification of the posterior mitral annulus. The patient refused surgical treatment.</p>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A calcificação do anel mitral é um achado ecocardiográfico comum, particularmente em idosos e doentes com insuficiência renal terminal em diálise. A degenerescêncica caseosa, ou necrose liquefeita, da calcificação do anel mitral é uma forma rara de calcificação do anel mitral. O reconhecimento precoce desta entidade evita procedimentos diagnósticos invasivos na medida em que é uma patologia benigna e, ao contrário de tumores e abcesso cardíacos, tem um bom prognóstico. Os autores apresentam o caso clínico de uma doente de 84 anos de idade com uma massa hiperecogénica ao nível do folheto posterior da válvula mitral, associada a insuficiência mitral severa. A ressonância magnética cardíaca demonstrou uma massa hipoperfundida, com realce tardio, após administração de gadolíneo. A tomografia computadorizada cardíaca evidenciou a natureza calcificada da lesão. Uma abordagem multi-imagem permitiu o diagnóstico de calcificação caseosa do anel mitral posterior. A doente recusou cirurgia cardíaca.</p>" ] ] "multimedia" => array:10 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 465 "Ancho" => 1298 "Tamanyo" => 68427 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Two-dimensional echocardiogram, parasternal long-axis view (A) and apical two-chamber view (B), revealing an echodense mass at the base of the posterior leaflet.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 595 "Ancho" => 751 "Tamanyo" => 47916 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Three-dimensional transthoracic echocardiogram with a visualization perspective from within the left ventricle. Note the mass involving the posterior mitral leaflet, distorting its shape.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 684 "Ancho" => 993 "Tamanyo" => 42378 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Three-dimensional transthoracic color flow imaging of mitral regurgitation, showing an eccentric jet originating from the posteromedial commissure.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 809 "Ancho" => 652 "Tamanyo" => 84265 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Transesophageal two-chamber view demonstrating severe mitral regurgitation.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 510 "Ancho" => 652 "Tamanyo" => 52555 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Steady-state free precession cine CMR image in modified two-chamber view, showing a hypointense mass (arrow) in the posterior region of the mitral annulus/basal segment of the inferior wall.</p>" ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 492 "Ancho" => 652 "Tamanyo" => 44398 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Steady-state free precession cine CMR image in basal short-axis view, demonstrating the mass (arrow).</p>" ] ] 6 => array:7 [ "identificador" => "fig0035" "etiqueta" => "Figure 7" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr7.jpeg" "Alto" => 458 "Ancho" => 749 "Tamanyo" => 37787 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Rest perfusion CMR imaging in short-axis view. Note the hypoperfusion of the mass compared to normal myocardium.</p>" ] ] 7 => array:7 [ "identificador" => "fig0040" "etiqueta" => "Figure 8" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr8.jpeg" "Alto" => 427 "Ancho" => 661 "Tamanyo" => 51280 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Phase-sensitive inversion-recovery CMR sequence showing late gadolinium enhancement in the peripheral margin of the mass.</p>" ] ] 8 => array:7 [ "identificador" => "fig0045" "etiqueta" => "Figure 9" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr9.jpeg" "Alto" => 312 "Ancho" => 787 "Tamanyo" => 34579 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Maximum intensity multislice CT projection showing a partially calcified hyperintense mass (arrow) in non-contrast acquisition (four-chamber and short-axis view).</p>" ] ] 9 => array:7 [ "identificador" => "fig0050" "etiqueta" => "Figure 10" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr10.jpeg" "Alto" => 438 "Ancho" => 907 "Tamanyo" => 43945 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Multislice CT volume-rendering technique revealing the extent of the mass (arrow) and its relation to the posterior mitral annulus.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Calcific atrial mass in end-stage renal failure" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "E. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 6 | 13 |
| 2024 October | 62 | 31 | 93 |
| 2024 September | 61 | 27 | 88 |
| 2024 August | 57 | 30 | 87 |
| 2024 July | 37 | 35 | 72 |
| 2024 June | 46 | 30 | 76 |
| 2024 May | 43 | 26 | 69 |
| 2024 April | 55 | 34 | 89 |
| 2024 March | 68 | 35 | 103 |
| 2024 February | 48 | 25 | 73 |
| 2024 January | 50 | 27 | 77 |
| 2023 December | 46 | 31 | 77 |
| 2023 November | 49 | 25 | 74 |
| 2023 October | 31 | 22 | 53 |
| 2023 September | 32 | 20 | 52 |
| 2023 August | 40 | 14 | 54 |
| 2023 July | 30 | 15 | 45 |
| 2023 June | 29 | 15 | 44 |
| 2023 May | 46 | 25 | 71 |
| 2023 April | 38 | 4 | 42 |
| 2023 March | 39 | 25 | 64 |
| 2023 February | 35 | 25 | 60 |
| 2023 January | 28 | 19 | 47 |
| 2022 December | 38 | 21 | 59 |
| 2022 November | 55 | 22 | 77 |
| 2022 October | 33 | 22 | 55 |
| 2022 September | 31 | 41 | 72 |
| 2022 August | 41 | 29 | 70 |
| 2022 July | 36 | 34 | 70 |
| 2022 June | 35 | 21 | 56 |
| 2022 May | 28 | 37 | 65 |
| 2022 April | 52 | 41 | 93 |
| 2022 March | 42 | 42 | 84 |
| 2022 February | 50 | 33 | 83 |
| 2022 January | 63 | 22 | 85 |
| 2021 December | 26 | 33 | 59 |
| 2021 November | 54 | 38 | 92 |
| 2021 October | 66 | 33 | 99 |
| 2021 September | 39 | 22 | 61 |
| 2021 August | 60 | 45 | 105 |
| 2021 July | 49 | 29 | 78 |
| 2021 June | 45 | 27 | 72 |
| 2021 May | 43 | 38 | 81 |
| 2021 April | 72 | 36 | 108 |
| 2021 March | 64 | 26 | 90 |
| 2021 February | 62 | 18 | 80 |
| 2021 January | 35 | 9 | 44 |
| 2020 December | 40 | 16 | 56 |
| 2020 November | 51 | 23 | 74 |
| 2020 October | 54 | 18 | 72 |
| 2020 September | 72 | 14 | 86 |
| 2020 August | 64 | 12 | 76 |
| 2020 July | 74 | 14 | 88 |
| 2020 June | 78 | 14 | 92 |
| 2020 May | 70 | 5 | 75 |
| 2020 April | 95 | 13 | 108 |
| 2020 March | 125 | 9 | 134 |
| 2020 February | 370 | 13 | 383 |
| 2020 January | 334 | 15 | 349 |
| 2019 December | 521 | 29 | 550 |
| 2019 November | 669 | 39 | 708 |
| 2019 October | 509 | 28 | 537 |
| 2019 September | 366 | 10 | 376 |
| 2019 August | 370 | 16 | 386 |
| 2019 July | 374 | 22 | 396 |
| 2019 June | 238 | 12 | 250 |
| 2019 May | 229 | 21 | 250 |
| 2019 April | 350 | 30 | 380 |
| 2019 March | 421 | 21 | 442 |
| 2019 February | 233 | 19 | 252 |
| 2019 January | 256 | 11 | 267 |
| 2018 December | 199 | 25 | 224 |
| 2018 November | 377 | 15 | 392 |
| 2018 October | 453 | 31 | 484 |
| 2018 September | 157 | 9 | 166 |
| 2018 August | 210 | 10 | 220 |
| 2018 July | 101 | 1 | 102 |
| 2018 June | 125 | 15 | 140 |
| 2018 May | 165 | 10 | 175 |
| 2018 April | 101 | 8 | 109 |
| 2018 March | 209 | 5 | 214 |
| 2018 February | 142 | 7 | 149 |
| 2018 January | 74 | 7 | 81 |
| 2017 December | 166 | 10 | 176 |
| 2017 November | 129 | 14 | 143 |
| 2017 October | 107 | 12 | 119 |
| 2017 September | 102 | 9 | 111 |
| 2017 August | 78 | 14 | 92 |
| 2017 July | 56 | 10 | 66 |
| 2017 June | 57 | 3 | 60 |
| 2017 May | 53 | 8 | 61 |
| 2017 April | 52 | 36 | 88 |
| 2017 March | 104 | 13 | 117 |
| 2017 February | 109 | 3 | 112 |
| 2017 January | 51 | 0 | 51 |
| 2016 December | 75 | 10 | 85 |
| 2016 November | 58 | 4 | 62 |
| 2016 October | 82 | 7 | 89 |
| 2016 September | 152 | 8 | 160 |
| 2016 August | 77 | 6 | 83 |
| 2016 July | 27 | 4 | 31 |
| 2016 June | 25 | 3 | 28 |
| 2016 May | 21 | 3 | 24 |
| 2016 April | 39 | 2 | 41 |
| 2016 March | 50 | 10 | 60 |
| 2016 February | 51 | 12 | 63 |
| 2016 January | 52 | 14 | 66 |
| 2015 December | 46 | 3 | 49 |
| 2015 November | 44 | 3 | 47 |
| 2015 October | 54 | 8 | 62 |
| 2015 September | 39 | 5 | 44 |
| 2015 August | 79 | 11 | 90 |
| 2015 July | 53 | 5 | 58 |
| 2015 June | 25 | 4 | 29 |
| 2015 May | 35 | 6 | 41 |
| 2015 April | 36 | 9 | 45 |
| 2015 March | 33 | 9 | 42 |
| 2015 February | 29 | 9 | 38 |
| 2015 January | 55 | 11 | 66 |
| 2014 December | 111 | 17 | 128 |
| 2014 November | 71 | 16 | 87 |
| 2014 October | 69 | 12 | 81 |
| 2014 September | 96 | 8 | 104 |
| 2014 August | 86 | 13 | 99 |
| 2014 July | 89 | 18 | 107 |
| 2014 June | 48 | 10 | 58 |
| 2014 May | 64 | 9 | 73 |
| 2014 April | 70 | 11 | 81 |
| 2014 March | 76 | 13 | 89 |
| 2014 February | 56 | 13 | 69 |
| 2014 January | 69 | 15 | 84 |
| 2013 December | 53 | 19 | 72 |
| 2013 November | 78 | 18 | 96 |
| 2013 October | 88 | 12 | 100 |
| 2013 September | 90 | 14 | 104 |
| 2013 August | 97 | 19 | 116 |
| 2013 July | 111 | 21 | 132 |
| 2013 June | 38 | 14 | 52 |
| 2013 May | 54 | 20 | 74 |
| 2013 April | 65 | 17 | 82 |
| 2013 March | 40 | 15 | 55 |
| 2013 February | 53 | 21 | 74 |
| 2013 January | 55 | 21 | 76 |
| 2012 December | 40 | 9 | 49 |
| 2012 November | 37 | 21 | 58 |
| 2012 October | 6 | 1 | 7 |
| 2012 September | 11 | 5 | 16 |
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