Case report
Coronary artery bypass after Kawasaki disease
Cirurgia de revascularização coronária após Doença de Kawasaki
Vera Santosa,
, Ana Sofia Simõesb, Ana Teixeirac, Miguel Abecasisd, Marília Loureiroe, Rui Anjosc
Corresponding author
a Serviço de Pediatria, Hospital de Faro, EPE, Faro, Portugal
b Serviço de Pediatria, Hospital Reynaldo dos Santos, Vila Franca de Xira, Portugal
c Serviço de Cardiologia Pediátrica, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
d Serviço de Cirurgia Cárdio-Torácica, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
e Serviço de Cardiologia Pediátrica, Hospital Maria Pia, Centro Hospitalar do Porto, Porto, Portugal
Read
12619
Timeswas read the article
2268
Total PDF
10351
Total HTML
Share statistics
array:25 [ "pii" => "S2174204912000773" "issn" => "21742049" "doi" => "10.1016/j.repce.2012.04.016" "estado" => "S300" "fechaPublicacion" => "2012-06-01" "aid" => "101" "copyright" => "Sociedade Portuguesa de Cardiologia" "copyrightAnyo" => "2010" "documento" => "article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "sco" "cita" => "Rev Port Cardiol. 2012;31:433-7" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 9526 "formatos" => array:3 [ "EPUB" => 177 "HTML" => 8322 "PDF" => 1027 ] ] "Traduccion" => array:1 [ "pt" => array:20 [ "pii" => "S0870255112000820" "issn" => "08702551" "doi" => "10.1016/j.repc.2012.04.002" "estado" => "S300" "fechaPublicacion" => "2012-06-01" "aid" => "101" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "sco" "cita" => "Rev Port Cardiol. 2012;31:433-7" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 10255 "formatos" => array:3 [ "EPUB" => 169 "HTML" => 8737 "PDF" => 1349 ] ] "pt" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Caso clínico</span>" "titulo" => "Cirurgia de revascularização coronária após doença de Kawasaki" "tienePdf" => "pt" "tieneTextoCompleto" => "pt" "tieneResumen" => array:2 [ 0 => "pt" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "433" "paginaFinal" => "437" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Coronary artery bypass after Kawasaki disease" ] ] "contieneResumen" => array:2 [ "pt" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "pt" => true ] "contienePdf" => array:1 [ "pt" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 678 "Ancho" => 950 "Tamanyo" => 99198 ] ] "descripcion" => array:1 [ "pt" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Telerradiografia de tórax – calcificação arrendondada (seta) na porção superior esquerda da silhueta cardíaca.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Vera Santos, Ana Sofia Simões, Ana Teixeira, Miguel Abecasis, Marília Loureiro, Rui Anjos" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Vera" "apellidos" => "Santos" ] 1 => array:2 [ "nombre" => "Ana Sofia" "apellidos" => "Simões" ] 2 => array:2 [ "nombre" => "Ana" "apellidos" => "Teixeira" ] 3 => array:2 [ "nombre" => "Miguel" "apellidos" => "Abecasis" ] 4 => array:2 [ "nombre" => "Marília" "apellidos" => "Loureiro" ] 5 => array:2 [ "nombre" => "Rui" "apellidos" => "Anjos" ] ] ] ] ] "idiomaDefecto" => "pt" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2174204912000773" "doi" => "10.1016/j.repce.2012.04.016" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204912000773?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255112000820?idApp=UINPBA00004E" "url" => "/08702551/0000003100000006/v1_201308021314/S0870255112000820/v1_201308021314/pt/main.assets" ] ] "itemSiguiente" => array:20 [ "pii" => "S2174204912000839" "issn" => "21742049" "doi" => "10.1016/j.repce.2011.11.023" "estado" => "S300" "fechaPublicacion" => "2012-06-01" "aid" => "110" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "sco" "cita" => "Rev Port Cardiol. 2012;31:439-44" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 9225 "formatos" => array:3 [ "EPUB" => 144 "HTML" => 8008 "PDF" => 1073 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Giant left ventricular pseudoaneurysm: The diagnostic contribution of different non-invasive imaging modalities" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "439" "paginaFinal" => "444" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Pseudoaneurisma gigante do ventrículo esquerdo: contributo diagnóstico de diferentes modalidades de imagem não invasivas" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1590 "Ancho" => 2333 "Tamanyo" => 199653 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Two-dimensional echocardiogram, in apical 4-chamber (A), short-axis (B), 2-chamber (C) and subcostal (D) views, showing a left ventricular pseudoaneurysm (Ps), with a narrow neck (arrow) extending infero-posteriorly and compressing the right ventricle (VD).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Sílvia Marta Oliveira, Paula Dias, Teresa Pinho, Cristina Gavina, Pedro Bernardo Almeida, António J. Madureira, Paulo Pinho, Isabel Ramos, Maria Júlia Maciel" "autores" => array:9 [ 0 => array:2 [ "nombre" => "Sílvia Marta" "apellidos" => "Oliveira" ] 1 => array:2 [ "nombre" => "Paula" "apellidos" => "Dias" ] 2 => array:2 [ "nombre" => "Teresa" "apellidos" => "Pinho" ] 3 => array:2 [ "nombre" => "Cristina" "apellidos" => "Gavina" ] 4 => array:2 [ "nombre" => "Pedro Bernardo" "apellidos" => "Almeida" ] 5 => array:2 [ "nombre" => "António J." "apellidos" => "Madureira" ] 6 => array:2 [ "nombre" => "Paulo" "apellidos" => "Pinho" ] 7 => array:2 [ "nombre" => "Isabel" "apellidos" => "Ramos" ] 8 => array:2 [ "nombre" => "Maria Júlia" "apellidos" => "Maciel" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "pt" => array:9 [ "pii" => "S0870255112000911" "doi" => "10.1016/j.repc.2012.04.009" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "pt" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255112000911?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204912000839?idApp=UINPBA00004E" "url" => "/21742049/0000003100000006/v1_201305151732/S2174204912000839/v1_201305151732/en/main.assets" ] "itemAnterior" => array:20 [ "pii" => "S2174204912000803" "issn" => "21742049" "doi" => "10.1016/j.repce.2012.01.016" "estado" => "S300" "fechaPublicacion" => "2012-06-01" "aid" => "106" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "ssu" "cita" => "Rev Port Cardiol. 2012;31:425-32" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 12531 "formatos" => array:3 [ "EPUB" => 208 "HTML" => 10624 "PDF" => 1699 ] ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review article</span>" "titulo" => "Hypertension in pregnancy: The current state of the art" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "425" "paginaFinal" => "432" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Hipertensão Arterial na Grávida: o actual estado da arte" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Sérgio Barra, Maria do Carmo Cachulo, Rui Providência, António Leitão-Marques" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Sérgio" "apellidos" => "Barra" ] 1 => array:2 [ "nombre" => "Maria do Carmo" "apellidos" => "Cachulo" ] 2 => array:2 [ "nombre" => "Rui" "apellidos" => "Providência" ] 3 => array:2 [ "nombre" => "António" "apellidos" => "Leitão-Marques" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "pt" => array:9 [ "pii" => "S087025511200087X" "doi" => "10.1016/j.repc.2012.04.006" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "pt" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S087025511200087X?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204912000803?idApp=UINPBA00004E" "url" => "/21742049/0000003100000006/v1_201305151732/S2174204912000803/v1_201305151732/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Coronary artery bypass after Kawasaki disease" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "433" "paginaFinal" => "437" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Vera Santos, Ana Sofia Simões, Ana Teixeira, Miguel Abecasis, Marília Loureiro, Rui Anjos" "autores" => array:6 [ 0 => array:4 [ "nombre" => "Vera" "apellidos" => "Santos" "email" => array:1 [ 0 => "verasantosm@yahoo.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Ana Sofia" "apellidos" => "Simões" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Ana" "apellidos" => "Teixeira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Miguel" "apellidos" => "Abecasis" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 4 => array:3 [ "nombre" => "Marília" "apellidos" => "Loureiro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] 5 => array:3 [ "nombre" => "Rui" "apellidos" => "Anjos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:5 [ 0 => array:3 [ "entidad" => "Serviço de Pediatria, Hospital de Faro, EPE, Faro, Portugal" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Serviço de Pediatria, Hospital Reynaldo dos Santos, Vila Franca de Xira, Portugal" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Serviço de Cardiologia Pediátrica, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal" "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Serviço de Cirurgia Cárdio-Torácica, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal" "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Serviço de Cardiologia Pediátrica, Hospital Maria Pia, Centro Hospitalar do Porto, Porto, Portugal" "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Cirurgia de revascularização coronária após Doença de Kawasaki" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1580 "Ancho" => 1583 "Tamanyo" => 231527 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Left coronary angiography: occluded right coronary artery (black arrow). The white arrows indicate the calcified aneurysm at the origin of the left descending artery.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Kawasaki disease (KD) is an acute systemic vasculitis of unknown etiology which principally affects children and occasionally adolescents. It is the main cause of acquired heart disease in children in developed countries.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Diagnosis is based on the classical clinical criteria of fever persisting at least five days and the presence of at least four of the following signs: changes in extremities, polymorphous exanthem, bilateral bulbar conjunctival injection without exudate, changes in lips and oral cavity, and cervical lymphadenopathy (>1.5<span class="elsevierStyleHsp" style=""></span>cm diameter).<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Incomplete KD should be considered in all children with unexplained fever for more than five days associated with two or three of the principal clinical features of KD; it is more frequent in young infants. Laboratory findings are non-specific, but they may help confirm the diagnosis, particularly in cases of incomplete KD.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The main complications are cardiovascular; coronary aneurysms are found in 15–25% of untreated children, although this can be reduced to 5% by administration of immunoglobulin in the first ten days of the disease.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The aneurysms may undergo various alterations: they may regress, stay unchanged, progress to stenotic or obstructive lesions (with or without recanalization or development of collateral vessels) and, very rarely, rupture, develop new lesions, or expand.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Stenosis of adjacent arteries can lead to ischemic coronary disease, myocardial infarction or sudden death.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Diagnosis of KD is a challenge, requiring a high degree of clinical suspicion; delay in diagnosis can lead to serious cardiovascular sequelae.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case report</span><p id="par0025" class="elsevierStylePara elsevierViewall">We present the case of a boy with a diagnosis of KD at the age of seven, in the context of fever of over five days’ duration, exanthem of the palms and soles, edema of the face and extremities, cervical lymphadenomegaly, and abdominal distension. Laboratory tests revealed elevated C-reactive protein and erythrocyte sedimentation rate, and thrombocytosis. Two weeks after disease onset, he was treated with IV gammaglobulin and aspirin, which was maintained for two months. Echocardiographic evaluation two weeks after onset of fever showed no alterations. He was followed in the outpatient pediatric clinic for three years, during which he remained asymptomatic; he was not referred for pediatric cardiology consultations, and echocardiography was not repeated.</p><p id="par0030" class="elsevierStylePara elsevierViewall">At the age of 11, he was referred to the pediatric cardiology department due to angina and exertional dyspnea of one month's evolution. The chest X-ray revealed a round area of calcification in the upper left portion of the cardiac silhouette (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). There were no alterations on the electrocardiogram (ECG). Echocardiography showed ectasia of the left coronary artery of 4 and 5<span class="elsevierStyleHsp" style=""></span>mm in the proximal and distal segments, respectively, with no wall motion abnormalities or mitral regurgitation. During nuclear perfusion scan with exercise, the patient reported chest discomfort at peak exercise, when the ECG showed ST-segment depression in II, III, aVF, V5 and V6. The nuclear perfusion scan during exercise showed severe hypoperfusion in the apex and the anteroseptal, apical-septal, and anteroapical segments and moderate hypoperfusion in the mid and basal segments of the anterior, inferior and inferoseptal walls, corresponding to the territories of the left anterior descending (LAD) artery and the right coronary artery (RCA), the alterations being reversed at rest. Cardiac catheterization revealed occlusion of the proximal segment of the LAD downstream of the calcified aneurysm, with retrograde filling by collateral circulation from the proximal branches of the left coronary artery (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), and of the proximal RCA, with retrograde filling by collateral circulation from the left coronary artery (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Left ventriculography demonstrated good function, with no ventricular aneurysmal alterations.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The patient underwent coronary artery bypass graft surgery without cardiopulmonary bypass, using a left internal mammary artery pedicle graft to revascularize the mid third of the LAD and the saphenous vein for the distal RCA. The surgery and postoperative period were uneventful and he was discharged medicated with aspirin at antiplatelet doses and propanolol.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Seven months after the operation, nuclear perfusion scanning with exercise showed no clinically significant ischemia, reflecting a good surgical result. The echocardiogram showed excellent global ventricular function, with no wall motion abnormalities.</p><p id="par0045" class="elsevierStylePara elsevierViewall">To date (one year after surgery), the patient has remained asymptomatic.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">Coronary artery alterations in KD can appear towards the end of the first week of illness and reach peak incidence and severity by four to six weeks.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In the acute phase, echocardiography is the method of choice for cardiovascular evaluation and should be performed as soon as the diagnosis is suspected, but treatment with IV immunoglobulin should not be delayed. For uncomplicated cases, if the initial echocardiogram is normal, it should be repeated at two and at six to eight weeks after onset of the disease. In a study by Scott et al., no patient with a normal echocardiogram at between two weeks and two months after disease onset presented abnormalities when assessed one year later. However, even if no coronary enlargement is present, there may be alterations in coronary function or coronary flow reserve, as well as aortic root dilatation, and so many authors recommend repeat echocardiography beyond eight weeks, although this is considered optional in the current AHA guidelines.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Closer monitoring is required with further diagnostic exams to guide management of children at higher risk (those with persistent fever or who exhibit coronary abnormalities, ventricular dysfunction, pericardial effusion, or valvular regurgitation); these complementary tests may include ECG, 24-hour ECG, exercise testing (ECG or echocardiography), nuclear perfusion scan, magnetic resonance imaging, computed tomography or cardiac catheterization.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,5</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In the present case, IV immunoglobulin therapy was begun late, increasing the risk of coronary complications. Although echocardiographic assessment was performed two weeks after disease onset, this showed no abnormalities, but no further assessments were performed, despite recommendations to the contrary. Presumably the aneurysm developed later, in accordance with the peak of incidence mentioned above, which was not detected because echocardiography was not repeated.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The AHA guidelines establish strategies for treatment and long-term follow-up according to risk stratification for myocardial ischemia. When an aneurysm is detected, antiplatelet and/or anticoagulant therapy should be continued depending on the size of the aneurysm; it is important to maintain regular follow-up with ECG, echocardiography and exercise testing. The recommended frequency of these exams varies according to coronary artery morphology, which determines ischemic risk.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,5</span></a> If the aneurysm is diagnosed early, close follow-up and complementary exams are called for. In the long term, in patients with complex lesions on echocardiography, wall motion abnormalities or evidence of ischemia (clinical signs or findings of complementary exams), coronary angiography provides more detailed anatomical information, making it possible to detect coronary stenosis or thrombotic occlusion and to determine the extent of collateral circulation.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Balloon angioplasty has not been successful when performed more than two years after the acute illness because of dense fibrosis and calcification in the arterial wall.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Percutaneous coronary intervention is indicated in patients with ischemic symptoms, ischemic alterations on exercise testing or severe stenotic lesions (≥75% stenosis) at risk of progressing to ischemia. It is contraindicated for individuals who have multiple, ostial, or long-segment lesions or left ventricular dysfunction.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Surgical revascularization may be considered in KD when there is severe occlusion of the left main coronary artery, of the proximal segment of the LAD, or of more than one major coronary artery, and/or when the collateral arteries are in jeopardy.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In the case presented, two major coronaries were affected with occlusion of the proximal segment of the LAD.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The preferred grafts for coronary artery bypass in these patients are the internal mammary arteries, since these grow with the somatic growth of children,<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,6</span></a> do not appear to be affected by atherosclerosis, and may have advantages in terms of endothelial function.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">In the present case, the left internal mammary artery was used for the LAD and the saphenous vein for the RCA. Saphenous vein grafts have shown good results in the right coronary circulation,<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a> with excellent long-term outcomes in children with KD.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">9</span></a> Furthermore, in this way the right internal mammary artery can be spared in case reoperation should be necessary in the future.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Kitamura et al.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> reported survival of 95% and an event-free rate of 60% at 25 years of follow-up after coronary artery bypass graft surgery in KD. In any event, regular follow-up should always be maintained, since there is a progressive decline in the event-free rate<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and endothelial function abnormalities persist many years after the acute phase, even in patients without coronary involvement.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusion</span><p id="par0095" class="elsevierStylePara elsevierViewall">This case report highlights the importance of early diagnosis and treatment of KD, bearing in mind its potential late complications. Patients with coronary alterations must be monitored clinically and by additional diagnostic techniques according to the clinical situation in order to detect ischemia early. When ischemic disease is present, there are precise indications for coronary artery bypass graft surgery and the medium-term results in this patient were excellent.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0100" 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" => "xres176218" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec164586" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres176217" "titulo" => "Resumo" ] 3 => array:2 [ "identificador" => "xpalclavsec164587" "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" => "Conclusion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2010-12-09" "fechaAceptado" => "2011-12-15" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec164586" "palabras" => array:3 [ 0 => "Kawasaki disease" 1 => "Coronary aneurysm" 2 => "Coronary artery bypass" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec164587" "palabras" => array:3 [ 0 => "Doença de Kawasaki" 1 => "Aneurismas coronários" 2 => "Cirurgia de revascularização coronária" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Kawasaki disease (KD) is a systemic vasculitis of unknown etiology, which is the main cause of acquired heart disease in children in developed countries. The main complications result from the development of coronary aneurysms which can lead to ischemic heart disease.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We present the case of a teenage boy with a diagnosis of KD at the age of seven. He was treated with gammaglobulin and aspirin and echocardiographic evaluation in the acute phase was apparently normal. At the age of 11, he developed chest pain and exertional dyspnea. Nuclear perfusion scans with exercise revealed hypoperfusion of the left anterior descending (LAD) and right coronary artery (RCA) territories. Cardiac catheterization showed occlusion of the proximal segments of both arteries. He underwent coronary artery bypass graft surgery (internal mammary artery bypass graft to the LAD and saphenous vein graft to the RCA), with a good clinical result.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">This case report highlights the importance of early diagnosis and treatment of KD and regular cardiological follow-up, bearing in mind the potential late complications of this pediatric disease.</p>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A doença de Kawasaki (DK) é uma vasculite sistémica, de etiologia desconhecida, constituindo a principal causa de cardiopatia adquirida em idade pediátrica em países desenvolvidos. As principais complicações resultam do aparecimento de aneurismas coronários que podem evoluir para doença coronária isquémica.</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Apresenta-se o caso clínico de um adolescente com diagnóstico de DK aos 7 anos. Efetuou terapêutica com imunoglobulina e ácido acetilsalicílico e a avaliação ecocardiográfica na fase aguda foi aparentemente normal. Aos 11 anos de idade desenvolveu quadro de angor e dispneia de esforço. A cintigrafia de perfusão miocárdica com prova de esforço revelou hipoperfusão dos territórios correspondentes às artérias descendente anterior esquerda (DA) e coronária direita (CD). O cateterismo cardíaco demonstrou oclusão dos segmentos proximais de ambas as artérias. Foi submetido a cirurgia de revascularização coronária (artéria mamária interna para a DA e veia safena interna para a CD) com boa evolução clínica e desaparecimento das alterações isquémicas na cintigrafia.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Este caso clínico vem alertar para a importância do diagnóstico e terapêutica atempados e seguimento posterior na DK, salientando-se a potencial gravidade das complicações cardiovasculares a longo prazo, desta doença pediátrica.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Santos, V; Cirurgia de revascularização coronária após Doença de Kawasaki. Rev Port Cardiol 2012. <span class="elsevierStyleInterRef" href="doi:10.1016/j.repc.2012.04.002">doi:10.1016/j.repc.2012.04.002</span></p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1118 "Ancho" => 1583 "Tamanyo" => 166810 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Chest X-ray. A round calcification (arrow) can be observed in the upper left portion of the cardiac silhouette.</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" => 4122 "Ancho" => 1388 "Tamanyo" => 594430 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">(A) Left coronary angiography: left anterior descending artery occluded distal to the calcified aneurysm (arrow). (B) Left coronary angiography showing calcified aneurysm (arrows). (C) Left coronary angiography: occluded left anterior descending artery with late retrograde filling by collaterals from the left coronary circulation (arrows).</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" => 1580 "Ancho" => 1583 "Tamanyo" => 231527 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Left coronary angiography: occluded right coronary artery (black arrow). The white arrows indicate the calcified aneurysm at the origin of the left descending artery.</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" => "Diagnosis, treatment, and long-term management of Kawasaki disease: a statement for health professionals from the committee on rheumatic fever, endocarditis and Kawasaki disease, Council on cardiovascular disease in the young, American Heart Association" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "J. Newburger" 1 => "M. Takahashi" 2 => "M. Gerber" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/01.CIR.0000145143.19711.78" "Revista" => array:6 [ "tituloSerie" => "Circulation" "fecha" => "2004" "volumen" => "110" "paginaInicial" => "2747" "paginaFinal" => "2771" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15505111" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnosis and therapy of Kawasaki disease in children" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A. Dajani" 1 => "K. Taubert" 2 => "M. Gerber" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Circulation" "fecha" => "1993" "volumen" => "87" "paginaInicial" => "1776" "paginaFinal" => "1780" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8491037" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Long-term outcome of Kawasaki disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "H. Senzaki" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/CIRCULATIONAHA.107.749515" "Revista" => array:6 [ "tituloSerie" => "Circulation" "fecha" => "2008" "volumen" => "118" "paginaInicial" => "2763" "paginaFinal" => "2772" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19106401" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cost-effective use of echocardiography in children with Kawasaki disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J. Scott" 1 => "J. Ettedgui" 2 => "W. Neches" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Pediatrics" "fecha" => "1999" "volumen" => "104" "paginaInicial" => "e57" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10545583" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Ogawa S, Akagi T, Ishii M, et al. Guidelines for diagnosis and management of cardiovascular sequelae in Kawasaki disease of the Japanese Circulation Society. Apresentado no Japanese Circulation Society Joint Working Groups; 2007." ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Twenty-five-year outcome of pediatric coronary artery bypass surgery for Kawasaki disease" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "S. Kitamura" 1 => "E. Tsuda" 2 => "J. Kobayashi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/CIRCULATIONAHA.108.840603" "Revista" => array:6 [ "tituloSerie" => "Circulation" "fecha" => "2009" "volumen" => "120" "paginaInicial" => "60" "paginaFinal" => "68" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19546384" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Complementary saphenous grafting: long-term follow-up" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "R. Dion" 1 => "D. Glineur" 2 => "D. Derouck" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1067/mtc.2001.115419" "Revista" => array:6 [ "tituloSerie" => "J Thorac Cardiovasc Surg" "fecha" => "2001" "volumen" => "122" "paginaInicial" => "296" "paginaFinal" => "304" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11479502" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Right coronary artery revascularization in patients undergoing bilateral thoracic artery grafting: comparison of the free internal thoracic artery with saphenous grafts" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "Y. Paz" 1 => "O. Lev-Ran" 2 => "C. Locker" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Interact Cardiovasc Thorac Surg" "fecha" => "2002" "volumen" => "1" "paginaInicial" => "93" "paginaFinal" => "98" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17669970" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0050" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Twenty-two-year follow-up of saphenous vein grafts in pediatric Kawasaki disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "Y. Suda" 1 => "Y. Takeuchi" 2 => "T. Ban" 3 => "S. Ichikawa" 4 => "R. Higashita" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Ann Thorac Surg" "fecha" => "2000" "volumen" => "70" "numero" => "5" "paginaInicial" => "1706" "paginaFinal" => "1708" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11093521" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0045" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Endothelial dysfunction late after Kawasaki disease" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "R. Dhillon" 1 => "P. Clarkson" 2 => "A. Donald" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Circulation" "fecha" => "1996" "volumen" => "94" "paginaInicial" => "2103" "paginaFinal" => "2106" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8901658" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21742049/0000003100000006/v1_201305151732/S2174204912000773/v1_201305151732/en/main.assets" "Apartado" => array:4 [ "identificador" => "9919" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case Reports" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21742049/0000003100000006/v1_201305151732/S2174204912000773/v1_201305151732/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204912000773?idApp=UINPBA00004E" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 6 | 13 |
| 2024 October | 33 | 24 | 57 |
| 2024 September | 30 | 24 | 54 |
| 2024 August | 39 | 25 | 64 |
| 2024 July | 23 | 30 | 53 |
| 2024 June | 32 | 27 | 59 |
| 2024 May | 41 | 15 | 56 |
| 2024 April | 33 | 26 | 59 |
| 2024 March | 39 | 21 | 60 |
| 2024 February | 28 | 26 | 54 |
| 2024 January | 28 | 18 | 46 |
| 2023 December | 35 | 22 | 57 |
| 2023 November | 35 | 21 | 56 |
| 2023 October | 33 | 17 | 50 |
| 2023 September | 29 | 23 | 52 |
| 2023 August | 29 | 12 | 41 |
| 2023 July | 22 | 10 | 32 |
| 2023 June | 26 | 11 | 37 |
| 2023 May | 38 | 23 | 61 |
| 2023 April | 19 | 5 | 24 |
| 2023 March | 41 | 16 | 57 |
| 2023 February | 37 | 21 | 58 |
| 2023 January | 29 | 12 | 41 |
| 2022 December | 41 | 24 | 65 |
| 2022 November | 46 | 30 | 76 |
| 2022 October | 35 | 17 | 52 |
| 2022 September | 31 | 36 | 67 |
| 2022 August | 28 | 28 | 56 |
| 2022 July | 36 | 30 | 66 |
| 2022 June | 33 | 28 | 61 |
| 2022 May | 23 | 37 | 60 |
| 2022 April | 39 | 25 | 64 |
| 2022 March | 34 | 24 | 58 |
| 2022 February | 31 | 37 | 68 |
| 2022 January | 25 | 22 | 47 |
| 2021 December | 22 | 26 | 48 |
| 2021 November | 32 | 43 | 75 |
| 2021 October | 38 | 37 | 75 |
| 2021 September | 35 | 23 | 58 |
| 2021 August | 32 | 25 | 57 |
| 2021 July | 13 | 22 | 35 |
| 2021 June | 32 | 20 | 52 |
| 2021 May | 44 | 48 | 92 |
| 2021 April | 87 | 67 | 154 |
| 2021 March | 64 | 20 | 84 |
| 2021 February | 103 | 18 | 121 |
| 2021 January | 36 | 8 | 44 |
| 2020 December | 26 | 2 | 28 |
| 2020 November | 40 | 30 | 70 |
| 2020 October | 23 | 13 | 36 |
| 2020 September | 41 | 14 | 55 |
| 2020 August | 22 | 5 | 27 |
| 2020 July | 59 | 9 | 68 |
| 2020 June | 50 | 11 | 61 |
| 2020 May | 37 | 4 | 41 |
| 2020 April | 50 | 11 | 61 |
| 2020 March | 26 | 7 | 33 |
| 2020 February | 67 | 29 | 96 |
| 2020 January | 38 | 12 | 50 |
| 2019 December | 41 | 2 | 43 |
| 2019 November | 41 | 2 | 43 |
| 2019 October | 50 | 8 | 58 |
| 2019 September | 34 | 8 | 42 |
| 2019 August | 36 | 8 | 44 |
| 2019 July | 34 | 11 | 45 |
| 2019 June | 28 | 4 | 32 |
| 2019 May | 31 | 8 | 39 |
| 2019 April | 40 | 12 | 52 |
| 2019 March | 43 | 10 | 53 |
| 2019 February | 63 | 13 | 76 |
| 2019 January | 66 | 6 | 72 |
| 2018 December | 62 | 12 | 74 |
| 2018 November | 128 | 9 | 137 |
| 2018 October | 262 | 20 | 282 |
| 2018 September | 172 | 13 | 185 |
| 2018 August | 121 | 11 | 132 |
| 2018 July | 63 | 3 | 66 |
| 2018 June | 86 | 6 | 92 |
| 2018 May | 122 | 14 | 136 |
| 2018 April | 233 | 6 | 239 |
| 2018 March | 206 | 6 | 212 |
| 2018 February | 131 | 0 | 131 |
| 2018 January | 113 | 6 | 119 |
| 2017 December | 199 | 7 | 206 |
| 2017 November | 129 | 8 | 137 |
| 2017 October | 81 | 12 | 93 |
| 2017 September | 84 | 10 | 94 |
| 2017 August | 105 | 9 | 114 |
| 2017 July | 99 | 5 | 104 |
| 2017 June | 125 | 12 | 137 |
| 2017 May | 153 | 6 | 159 |
| 2017 April | 92 | 10 | 102 |
| 2017 March | 141 | 33 | 174 |
| 2017 February | 116 | 3 | 119 |
| 2017 January | 67 | 4 | 71 |
| 2016 December | 86 | 21 | 107 |
| 2016 November | 68 | 7 | 75 |
| 2016 October | 69 | 13 | 82 |
| 2016 September | 81 | 11 | 92 |
| 2016 August | 47 | 0 | 47 |
| 2016 July | 49 | 10 | 59 |
| 2016 June | 44 | 12 | 56 |
| 2016 May | 71 | 6 | 77 |
| 2016 April | 65 | 1 | 66 |
| 2016 March | 108 | 23 | 131 |
| 2016 February | 119 | 28 | 147 |
| 2016 January | 90 | 18 | 108 |
| 2015 December | 107 | 12 | 119 |
| 2015 November | 88 | 9 | 97 |
| 2015 October | 114 | 14 | 128 |
| 2015 September | 86 | 11 | 97 |
| 2015 August | 114 | 12 | 126 |
| 2015 July | 146 | 7 | 153 |
| 2015 June | 87 | 5 | 92 |
| 2015 May | 100 | 12 | 112 |
| 2015 April | 89 | 11 | 100 |
| 2015 March | 119 | 6 | 125 |
| 2015 February | 114 | 3 | 117 |
| 2015 January | 64 | 9 | 73 |
| 2014 December | 77 | 18 | 95 |
| 2014 November | 70 | 7 | 77 |
| 2014 October | 73 | 7 | 80 |
| 2014 September | 110 | 13 | 123 |
| 2014 August | 71 | 10 | 81 |
| 2014 July | 77 | 12 | 89 |
| 2014 June | 85 | 6 | 91 |
| 2014 May | 77 | 12 | 89 |
| 2014 April | 82 | 8 | 90 |
| 2014 March | 97 | 15 | 112 |
| 2014 February | 93 | 14 | 107 |
| 2014 January | 115 | 14 | 129 |
| 2013 December | 91 | 12 | 103 |
| 2013 November | 114 | 22 | 136 |
| 2013 October | 87 | 13 | 100 |
| 2013 September | 89 | 11 | 100 |
| 2013 August | 115 | 16 | 131 |
| 2013 July | 115 | 22 | 137 |
| 2013 June | 90 | 11 | 101 |
| 2013 May | 88 | 18 | 106 |
| 2013 April | 99 | 23 | 122 |
| 2013 March | 105 | 18 | 123 |
| 2013 February | 80 | 25 | 105 |
| 2013 January | 101 | 27 | 128 |
| 2012 December | 85 | 15 | 100 |
| 2012 November | 86 | 23 | 109 |
| 2012 October | 96 | 18 | 114 |
| 2012 September | 36 | 3 | 39 |
Show all
