Case report
Retinal artery embolization complicating Libman-Sacks endocarditis in a systemic lupus erythematosus patient
Endocardite de Libman-Sacks complicada por embolização da artéria da retina num doente com LES
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GC: guiding catheter; Kn: knot; Sh: sheath.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Nuri Ilker Akkus, Faisal Bahadur, Jai Varma" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Nuri Ilker" "apellidos" => "Akkus" ] 1 => array:2 [ "nombre" => "Faisal" "apellidos" => "Bahadur" ] 2 => array:2 [ "nombre" => "Jai" "apellidos" => "Varma" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204913001013?idApp=UINPBA00004E" "url" => "/21742049/0000003200000004/v1_201308021404/S2174204913001013/v1_201308021404/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Retinal artery embolization complicating Libman-Sacks endocarditis in a systemic lupus erythematosus patient" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "345" "paginaFinal" => "347" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Liliana Marta, Maria Luz Pitta, Marisa Peres, Vítor Ferreira, Maria Clotilde Puga, Davide Severino, Graça Ferreira da Silva" "autores" => array:7 [ 0 => array:4 [ "nombre" => "Liliana" "apellidos" => "Marta" "email" => array:1 [ 0 => "liliana.marta@gmail.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" => "Maria Luz" "apellidos" => "Pitta" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Marisa" "apellidos" => "Peres" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Vítor" "apellidos" => "Ferreira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "Maria Clotilde" "apellidos" => "Puga" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "Davide" "apellidos" => "Severino" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 6 => array:3 [ "nombre" => "Graça Ferreira da" "apellidos" => "Silva" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Serviço de Cardiologia, Hospital de Santarém, Santarém, Portugal" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Oftalmologia, Hospital de Santarém, Santarém, 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" => "Endocardite de Libman-Sacks complicada por embolização da artéria da retina num doente com LES" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 803 "Ancho" => 2167 "Tamanyo" => 143310 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiogram showing vegetation (Veg.) on the ventricular side of the posterior mitral leaflet (PML) and aortic valve (AoV) with thickened leaflets.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case report</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 73-year-old woman with a history of systemic lupus erythematosus (SLE) diagnosed 15 years ago, treated with corticosteroids and hydroxychloroquine, presented to an ophthalmology consultation after a three-hour period of sudden and marked decreased right visual acuity. No other symptoms were reported, including fever or localized weakness. Fundoscopic examination showed a pale retina with a cherry-red macula (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>) and a diagnosis of right central retinal artery occlusion was made.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Transthoracic and transesophageal echocardiography revealed the presence of a mass attached to the ventricular side of the posterior mitral leaflet, with a vibratory motion, a maximum diameter of 13 mm, irregular shape and heterogeneous echogenicity, consistent with vegetation (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>). The aortic valve had thickened leaflets (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>) and moderate regurgitation by color Doppler.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Carotid Doppler ultrasound showed no significant atherosclerotic lesions and no other cardioembolic sources were detected.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Inflammatory parameters (white blood cell count 6.9<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>/l, C-reactive protein 1.6 mg/dl and erythrocyte sedimentation rate 44 mm/h) were not suggestive of infection. Blood cultures were negative. Autoimmunity study revealed antinuclear antibodies positive at a titer of 1/320, with no other positive antibodies, including negative antiphospholipid antibodies (APA). C3 and C4 levels were normal. Thrombophilia tests including C and S protein levels, antithrombin III and resistance to activated protein C were also normal.</p><p id="par0025" class="elsevierStylePara elsevierViewall">We assumed a diagnosis of Libman-Sacks endocarditis (LSE) and the patient started anticoagulation therapy. A follow-up transesophageal echocardiogram four weeks later showed resolution of the previously described vegetation. There was no recurrence of thromboembolic events.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">SLE is an autoimmune disease that causes multiorgan inflammatory damage. In recent decades, with increasing survival and advances in diagnostic techniques, particularly in echocardiography, cardiac disease associated with SLE has become more evident.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Valvular disease is one of the main cardiac manifestations of SLE and can occur in the form of valvular thickening, masses or noninfective vegetations (LSE), valvular regurgitation and valvular stenosis.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">LSE was first described in 1924 by Libman and Sacks in four patients with SLE and noninfective verrucous vegetations.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Libman-Sacks vegetations develop mainly on the mitral valve, followed by the aortic valve, but may develop on any other valve, on the subvalvular apparatus or on the surface of the endocardium.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> They are usually located on the atrial side of the mitral valve leaflets or the vessel side of the aortic valve leaflets.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">A significant proportion of patients with SLE have LSE detected in autopsy studies (30–50%). However, the real prevalence of LSE remains unknown since most patients with Libman-Sacks vegetations have asymptomatic valve abnormalities.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Moyssakis et al.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> studied 342 patients with SLE by echocardiography over four years and found an 11% incidence of LSE and an association with lupus duration, disease activity, presence of anticardiolipin antibody and manifestations of antiphospholipid syndrome. Roldan et al.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> studied 69 patients with SLE by transesophageal echocardiography and found a 43% incidence of LSE, which may be related to the greater accuracy of this modality.</p><p id="par0050" class="elsevierStylePara elsevierViewall">It has been proposed that LSE is due to the formation of fibrin-platelet thrombi on the injured valve, followed by tissue organization and leading to valvular fibrosis, distortion and subsequent dysfunction. Recent studies have shown deposition of immunoglobulins and complement in the valvular structure which subsequently developed LSE and valvular thickening.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The association of LSE and APA has been widely investigated and has been reported in several studies,<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,4,5</span></a> although others have found no connection.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The role of APA in the pathogenesis of valvular disease is thought to be by promoting thrombus formation on injured valve endothelium and inflammatory changes, rather than a more direct pathogenic role.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Further, the observation that there is a significantly higher prevalence of valvular lesions in patients with antiphospholipid syndrome (APS) secondary to SLE than in those with primary APS may mean that there are SLE-related factors that promote endocardial damage and contribute to this difference.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,4</span></a> APA were not detected in our patient, which is in agreement with this theory.</p><p id="par0060" class="elsevierStylePara elsevierViewall">One recognized complication of LSE is the development of secondary infectious endocarditis<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> which increases the complexity of differential diagnosis in a patient with SLE who presents with a valve mass. Infective endocarditis lesions are usually located at the leaflet's line of closure, are homogeneous in echogenicity and may show a vibratory or rotatory motion.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In contrast, LSE lesions are usually located at the base, middle or tip of the leaflets and are variable in shape and size and heterogeneous in echogenicity.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Thus it is imperative to differentiate between these two clinical identities, since management and treatment are quite different. Our patient had no fever, her leukocyte count was normal and blood cultures were negative, which enabled us to reach a diagnosis of LSE and to initiate anticoagulation therapy. Follow-up transesophageal echocardiography provided an assessment of disease progression, revealing the regression of the previously observed vegetation.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The main clinical impact of LSE is related to the probability of lesion progression to valvular dysfunction and the tendency to thromboembolic events, especially stroke or transient ischemic attack.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3,4</span></a> The incidence of thromboembolic cerebrovascular events in patients with LSE has been reported as 10–20%<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a> and a cardioembolic origin was assumed in most cases. In our search of the literature we found several case reports of distal embolization from LSE, the majority reporting cerebral embolization, but none with retinal embolization.</p><p id="par0070" class="elsevierStylePara elsevierViewall">In the present case, there was an occlusion of the right central retinal artery, which originates from the ophthalmic artery, the first intracranial branch of the internal carotid artery. Given the temporal relationship between the onset of right blindness and the echocardiographic finding of a mass adhering to the mitral valve, it was assumed that the retinal artery occlusion was cardioembolic in origin. The patient was started on anticoagulation therapy for secondary thromboprophylaxis and remission of the previously detected vegetation was achieved. To date she has had no new thromboembolic events.</p><p id="par0075" class="elsevierStylePara elsevierViewall">With this case report we highlight the importance of awareness of this entity, allowing rapid referral for cardiovascular examination and thus enabling early diagnosis and appropriate intervention.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Given that most patients with SLE and valvular disease have no cardiac symptoms, a careful cardiovascular examination should be made periodically. Since strokes in patients with SLE are frequent and, on the other hand, valvular thickening and vegetations are common and can act as substrates for cardioembolism, prophylactic therapy with anticoagulation may be an appropriate approach to these patients.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Ethical disclosures</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Protection of human and animal subjects</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Confidentiality of data</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Right to privacy and informed consent</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0035" 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:9 [ 0 => array:2 [ "identificador" => "xres251735" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec239330" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres251736" "titulo" => "Resumo" ] 3 => array:2 [ "identificador" => "xpalclavsec239331" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Right to privacy and informed consent" ] ] ] 7 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-07-12" "fechaAceptado" => "2012-04-23" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec239330" "palabras" => array:4 [ 0 => "Systemic lupus erythematosus" 1 => "Libman-Sacks endocarditis" 2 => "Embolization" 3 => "Retinal artery occlusion" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec239331" "palabras" => array:4 [ 0 => "Lúpus eritematoso sistémico" 1 => "Endocardite de Libman-Sacks" 2 => "Embolização" 3 => "Oclusão da artéria da retina" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Libman-Sacks endocarditis (LSE) is the most characteristic cardiac manifestation of systemic lupus erythematosus (SLE). It is usually clinically silent but heart failure due to valvular dysfunction, secondary infective endocarditis and embolic phenomena can complicate valvular abnormalities. We present a patient with SLE and blindness due to right central retinal artery occlusion. Echocardiographic examination revealed a verrucous vegetation on the posterior mitral valve leaflet consistent with LSE. Anticoagulation therapy was started. Echocardiographic regression of the vegetation was observed and there has been no recurrence of thromboembolic events to date.</p>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A endocardite de Libman-Sacks é a manifestação cardíaca mais característica do LES. É habitualmente clinicamente silenciosa, mas a insuficiência cardíaca por disfunção valvular, a endocardite infecciosa secundária e os fenómenos embólicos podem complicar as alterações valvulares. Apresentamos um caso clínico de uma doente com LES e amaurose à direita por trombose da artéria central da retina. O ecocardiograma mostrou uma vegetação verrucosa no folheto posterior da válvula mitral, compatível com endocardite de Libman-Sacks. A doente iniciou terapêutica com anticoagulação, verificou-se regressão da vegetação descrita e não teve recorrência de eventos tromboembólicos até à data.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 647 "Ancho" => 850 "Tamanyo" => 87821 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Right eye fundoscopic examination showing a pale retina with a cherry-red macula.</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" => 803 "Ancho" => 2167 "Tamanyo" => 143310 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiogram showing vegetation (Veg.) on the ventricular side of the posterior mitral leaflet (PML) and aortic valve (AoV) with thickened leaflets.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Libman-Sacks endocarditis in systemic lupus erythematosus: prevalence, associations, and evolution" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "I. 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Ziporen" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Circulation" "fecha" => "1996" "volumen" => "93" "paginaInicial" => "1579" "paginaFinal" => "1587" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8608627" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Association of antiphospholipid antibodies with valvulopathy in systemic lupus erythematosus: a systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "P. Mattos" 1 => "M.B. Santiago" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s10067-010-1662-5" "Revista" => array:6 [ "tituloSerie" => "Clin Rheumatol" "fecha" => "2011" "volumen" => "30" "paginaInicial" => "165" "paginaFinal" => "171" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21207090" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Systemic lupus erythematosus valve disease by transesophageal echocardiography and the role of antiphospholipid antibodies" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "C.A. Roldan" 1 => "B.K. Shively" 2 => "C.C. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 14 | 5 | 19 |
| 2024 October | 67 | 31 | 98 |
| 2024 September | 107 | 22 | 129 |
| 2024 August | 88 | 27 | 115 |
| 2024 July | 56 | 34 | 90 |
| 2024 June | 75 | 28 | 103 |
| 2024 May | 86 | 29 | 115 |
| 2024 April | 83 | 36 | 119 |
| 2024 March | 105 | 17 | 122 |
| 2024 February | 99 | 21 | 120 |
| 2024 January | 84 | 24 | 108 |
| 2023 December | 104 | 29 | 133 |
| 2023 November | 100 | 21 | 121 |
| 2023 October | 56 | 12 | 68 |
| 2023 September | 44 | 22 | 66 |
| 2023 August | 39 | 23 | 62 |
| 2023 July | 51 | 4 | 55 |
| 2023 June | 58 | 12 | 70 |
| 2023 May | 50 | 26 | 76 |
| 2023 April | 34 | 4 | 38 |
| 2023 March | 39 | 22 | 61 |
| 2023 February | 47 | 22 | 69 |
| 2023 January | 43 | 19 | 62 |
| 2022 December | 58 | 21 | 79 |
| 2022 November | 69 | 29 | 98 |
| 2022 October | 54 | 16 | 70 |
| 2022 September | 38 | 24 | 62 |
| 2022 August | 37 | 33 | 70 |
| 2022 July | 39 | 36 | 75 |
| 2022 June | 38 | 26 | 64 |
| 2022 May | 37 | 60 | 97 |
| 2022 April | 34 | 24 | 58 |
| 2022 March | 42 | 28 | 70 |
| 2022 February | 36 | 27 | 63 |
| 2022 January | 68 | 21 | 89 |
| 2021 December | 40 | 31 | 71 |
| 2021 November | 39 | 42 | 81 |
| 2021 October | 49 | 40 | 89 |
| 2021 September | 30 | 30 | 60 |
| 2021 August | 38 | 30 | 68 |
| 2021 July | 29 | 26 | 55 |
| 2021 June | 29 | 31 | 60 |
| 2021 May | 42 | 37 | 79 |
| 2021 April | 43 | 36 | 79 |
| 2021 March | 62 | 16 | 78 |
| 2021 February | 69 | 16 | 85 |
| 2021 January | 36 | 7 | 43 |
| 2020 December | 31 | 7 | 38 |
| 2020 November | 48 | 15 | 63 |
| 2020 October | 44 | 6 | 50 |
| 2020 September | 74 | 8 | 82 |
| 2020 August | 48 | 5 | 53 |
| 2020 July | 60 | 3 | 63 |
| 2020 June | 58 | 6 | 64 |
| 2020 May | 50 | 2 | 52 |
| 2020 April | 51 | 11 | 62 |
| 2020 March | 72 | 11 | 83 |
| 2020 February | 124 | 10 | 134 |
| 2020 January | 46 | 10 | 56 |
| 2019 December | 57 | 6 | 63 |
| 2019 November | 38 | 5 | 43 |
| 2019 October | 60 | 4 | 64 |
| 2019 September | 83 | 12 | 95 |
| 2019 August | 36 | 5 | 41 |
| 2019 July | 36 | 12 | 48 |
| 2019 June | 47 | 6 | 53 |
| 2019 May | 48 | 5 | 53 |
| 2019 April | 33 | 14 | 47 |
| 2019 March | 135 | 13 | 148 |
| 2019 February | 101 | 10 | 111 |
| 2019 January | 102 | 10 | 112 |
| 2018 December | 101 | 13 | 114 |
| 2018 November | 80 | 5 | 85 |
| 2018 October | 167 | 20 | 187 |
| 2018 September | 48 | 13 | 61 |
| 2018 August | 44 | 4 | 48 |
| 2018 July | 35 | 4 | 39 |
| 2018 June | 53 | 7 | 60 |
| 2018 May | 65 | 8 | 73 |
| 2018 April | 52 | 4 | 56 |
| 2018 March | 73 | 6 | 79 |
| 2018 February | 45 | 4 | 49 |
| 2018 January | 41 | 4 | 45 |
| 2017 December | 88 | 8 | 96 |
| 2017 November | 36 | 5 | 41 |
| 2017 October | 42 | 7 | 49 |
| 2017 September | 45 | 9 | 54 |
| 2017 August | 45 | 9 | 54 |
| 2017 July | 29 | 7 | 36 |
| 2017 June | 42 | 7 | 49 |
| 2017 May | 71 | 4 | 75 |
| 2017 April | 35 | 2 | 37 |
| 2017 March | 68 | 10 | 78 |
| 2017 February | 76 | 2 | 78 |
| 2017 January | 51 | 2 | 53 |
| 2016 December | 67 | 10 | 77 |
| 2016 November | 37 | 6 | 43 |
| 2016 October | 61 | 6 | 67 |
| 2016 September | 76 | 9 | 85 |
| 2016 August | 35 | 3 | 38 |
| 2016 July | 32 | 3 | 35 |
| 2016 June | 34 | 2 | 36 |
| 2016 May | 18 | 2 | 20 |
| 2016 April | 24 | 1 | 25 |
| 2016 March | 24 | 7 | 31 |
| 2016 February | 51 | 14 | 65 |
| 2016 January | 45 | 6 | 51 |
| 2015 December | 44 | 5 | 49 |
| 2015 November | 37 | 4 | 41 |
| 2015 October | 47 | 5 | 52 |
| 2015 September | 50 | 7 | 57 |
| 2015 August | 42 | 5 | 47 |
| 2015 July | 35 | 8 | 43 |
| 2015 June | 18 | 2 | 20 |
| 2015 May | 36 | 5 | 41 |
| 2015 April | 41 | 10 | 51 |
| 2015 March | 26 | 4 | 30 |
| 2015 February | 41 | 5 | 46 |
| 2015 January | 43 | 5 | 48 |
| 2014 December | 52 | 7 | 59 |
| 2014 November | 54 | 5 | 59 |
| 2014 October | 48 | 3 | 51 |
| 2014 September | 60 | 4 | 64 |
| 2014 August | 68 | 3 | 71 |
| 2014 July | 65 | 10 | 75 |
| 2014 June | 57 | 7 | 64 |
| 2014 May | 45 | 15 | 60 |
| 2014 April | 67 | 3 | 70 |
| 2014 March | 46 | 12 | 58 |
| 2014 February | 39 | 3 | 42 |
| 2014 January | 45 | 11 | 56 |
| 2013 December | 41 | 9 | 50 |
| 2013 November | 43 | 6 | 49 |
| 2013 October | 40 | 10 | 50 |
| 2013 September | 45 | 10 | 55 |
| 2013 August | 44 | 11 | 55 |
| 2013 July | 38 | 8 | 46 |
| 2013 June | 11 | 2 | 13 |
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