Case report
A case of constrictive pericarditis and thoracic aortic aneurysm: A hybrid therapeutic approach
Um caso de pericardite constritiva e aneurisma da aorta torácica: abordagem terapêutica híbrida
Maria Salomé Carvalho
, Pedro Jerónimo de Sousa, Pedro de Araújo Gonçalves, Hélder Dores, Miguel Abecasis, Manuel Almeida, Miguel Mendes
Corresponding author
Serviço de Cardiologia, Hospital de Santa Cruz, Oeiras, Portugal
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"Almeida" ] 6 => array:2 [ "nombre" => "Miguel" "apellidos" => "Mendes" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Serviço de Cardiologia, Hospital de Santa Cruz, Oeiras, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Um caso de pericardite constritiva e aneurisma da aorta torácica: abordagem terapêutica híbrida" ] ] "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" => 2527 "Ancho" => 1585 "Tamanyo" => 683740 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">(A) Construction of three-branch graft; (B) total debranching of supra-aortic branches (left brachiocephalic, carotid and subclavian arteries).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Constrictive pericarditis is a rare and disabling consequence of pericardial thickening secondary to chronic inflammation, which may be due to infection (particularly tuberculosis, which has a high prevalence in Portugal), or a late complication of mediastinal irradiation, or following cardiac surgery.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Less common causes are connective tissue disease, end-stage renal failure and cancer, although in the latter, the pathophysiology is different since the thickening results not only from the inflammatory process but also from tumor invasion of the pericardium. Treatment consists of pericardiectomy, except in completely asymptomatic cases or in patients contraindicated for this surgical procedure, in whom diuretic therapy may be an option.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Aortic aneurysms, defined as pathological dilatation of ≥1.5 times normal diameter, are usually asymptomatic and are incidental findings on routine exams performed for other reasons. Various risk factors have been suggested, including hypertension, smoking and chronic obstructive pulmonary disease, and a variety of causes have been identified: cystic medial degeneration, atherosclerosis, trauma, inflammation or infection, post-stenotic or post-surgical dilatation, and familial syndromes such as Marfan and Ehlers-Danlos type IV.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The therapeutic approach is often conservative, with medical therapy and vigilance in cases of asymptomatic aneurysms and/or those considered too small for surgical intervention. In symptomatic aneurysms and those of sufficient size, treatment is invasive, with surgical or percutaneous implantation of an endovascular prosthesis.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5–7</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0025" class="elsevierStylePara elsevierViewall">A 59-year-old man, a former smoker, with hypertension, chronic renal failure undergoing hemodialysis and a history of miliary tuberculosis in 2002 (under therapy for 12 months), had an abdominal aortic aneurysm diagnosed and treated by implantation of an aortic endoprosthesis in 2005. He had also had ulcerative colitis, treated by total colectomy and ileostomy. He was under medication with atenolol 50 mg, amlodipine 10 mg, indapamide 20 mg, an intestinal anti-inflammatory drug (mesalazine 500 mg), a phosphorus-binding agent and a multivitamin supplement.</p><p id="par0030" class="elsevierStylePara elsevierViewall">He was referred for cardiology consultation in July 2011, complaining of fatigue (New York Heart Association [NYHA] class III). Physical examination revealed no alterations except mild bilateral pretibial edema. The electrocardiogram showed sinus rhythm, heart rate 92 bpm, with left anterior hemiblock, but no other changes.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Other diagnostic exams were requested, including transthoracic echocardiography, which showed characteristics compatible with constrictive pericarditis – pericardial thickening with increased echogenicity and significant respiratory variation of the E wave in transmitral flow (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A and B), together with mildly impaired ejection fraction.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Right and left cardiac catheterization excluded angiographically significant coronary artery lesions; the diagnosis of constrictive pericarditis was confirmed through hemodynamic study, which showed typical dip-and-plateau ventricular pressure curves and equalization of end-diastolic pressures.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Aortography documented dilatation of the descending thoracic aorta. Chest computed tomography (CT) angiography to better characterize the aorta revealed a large, partially thrombosed, saccular aneurysm originating in the descending thoracic aorta, immediately distal to the emergence of the left subclavian artery, 87 mm × 61 mm in diameter (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>). No pericardial calcification was observed.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Following joint medical and surgical evaluation, it was decided to adopt a hybrid surgical and percutaneous approach. Surgery consisted of pericardiectomy with total debranching of the supra-aortic branches (left brachiocephalic trunk and carotid and subclavian arteries) with termino-lateral anastomosis of a previously constructed three-branch Dacron graft (Uni-Graft<span class="elsevierStyleSup">®</span> KUV, B. Braun) (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>A) to the aortic arch, obviating the need for extracorporeal circulation and deep hypothermia (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>B).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Percutaneous implantation of an endoprosthesis in the thoracic aorta (<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>) was then performed, taking care not to compromise the emergence of the above vessels.</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Anatomopathological study of the pericardium showed non-specific pericarditis. The postoperative period was uneventful and the patient was discharged after nine days.</p><p id="par0065" class="elsevierStylePara elsevierViewall">CT angiography three months after the interventions confirmed a good result (<a class="elsevierStyleCrossRef" href="#fig0025">Figure 5</a>).</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">At six-month follow-up, the patient was in NYHA class II/III, with no complications or rehospitalizations.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0075" class="elsevierStylePara elsevierViewall">Descending thoracic aortic aneurysms originating in the aortic arch are not uncommon<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> but represent a technical challenge, due to both the involvement of the supra-aortic branches, with their high blood flow, and the curved anatomy and motion of this portion of the aorta during the cardiac cycle.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Conventional surgical treatment requires extracorporeal circulation and deep hypothermia, which, despite advances in knowledge and techniques, still carries significant risk of mortality and morbidity,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> particularly myocardial injury and an appreciable incidence of permanent neurological damage.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Less invasive strategies, with reduced physiological insult, have therefore become increasingly popular. There is growing evidence that combined percutaneous and surgical treatment of these aneurysms is associated with lower morbidity and mortality in patients who are not ideal candidates for conventional surgery.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11–15</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Percutaneous implantation of an endoprosthesis is a safe and effective alternative, although it requires a proximal landing zone in the area to be treated that will allow the prosthesis to be anchored without compromising blood supply to the supra-aortic branches. This limitation can be overcome by repositioning these branches proximal to the endoprosthesis implantation site, a technique termed debranching.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Discussion of the etiology of the present case focused on the fact that both the pericardial inflammation and aortic wall degeneration could be cardiovascular manifestations of a single systemic disease.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Although both hypertension and smoking can cause aortic aneurysms, chronic renal failure (by accelerating the atherosclerotic process) and ulcerative colitis (by establishing a systemic inflammatory state) can also be implicated. The latter association has been reported in the literature.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">With regard to pericardial involvement, both chronic renal failure and ulcerative colitis<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> are associated, albeit rarely, with chronic pericarditis.</p><p id="par0110" class="elsevierStylePara elsevierViewall">However, tuberculosis, while rarely described in association with aortic aneurysms, is a common cause of constrictive pericarditis (particularly in Portugal), and merits consideration as the cause of both conditions in this case.</p><p id="par0115" class="elsevierStylePara elsevierViewall">Aortic degeneration is a rare sequela of tuberculosis, first described by Weigert in 1882.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Since then, tuberculous arteritis of the subclavian, carotid, common iliac, hepatic, renal and innominate arteries has been reported.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19–21</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">At least three different mechanisms have been suggested: extension of a contiguous focus of infection (for example, from the pulmonary parenchyma or pericardium to the thoracic aorta or from infected retroperitoneal lymph nodes to the abdominal aorta); hematogenous spread of a pre-existing intimal lesion such as an atherosclerotic plaque; and septic embolism from the arterial wall to vessels or lymph nodes.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22,23</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Tuberculous aortitis can lead to complete degeneration of the aortic wall or aneurysm formation,<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> and diagnosis is a challenge requiring a high level of clinical suspicion.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0130" class="elsevierStylePara elsevierViewall">The case presented is interesting for the variety of cardiovascular diagnoses that could be manifestations of a single disease, for the diagnostic process involved, and for the complex therapeutic solution that combined surgical and percutaneous intervention, a practical illustration of how a heart team works.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Protection of human and animal subjects</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Confidentiality of data</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data and that all the patients included in the study received sufficient information and gave their written informed consent to participate in the study.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Right to privacy and informed consent</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflicts of interest</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:2 [ "identificador" => "xres247142" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec234434" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres247143" "titulo" => "Resumo" ] 3 => array:2 [ "identificador" => "xpalclavsec234433" "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:3 [ "identificador" => "sec0025" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-07-31" "fechaAceptado" => "2012-08-02" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec234434" "palabras" => array:3 [ 0 => "Constrictive pericarditis" 1 => "Aortic aneurysm" 2 => "Aortic debranching" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec234433" "palabras" => array:3 [ 0 => "Pericardite constritiva" 1 => "Aneurisma aórtico" 2 => "<span class="elsevierStyleItalic">Debranching</span> aórtico" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The authors describe the case of a 59-year-old man, a former smoker, with hypertension, chronic renal failure undergoing hemodialysis, and a history of stent grafting for repair of an abdominal aortic aneurysm and miliary tuberculosis, who was diagnosed with constrictive pericarditis and a thoracic aortic aneurysm. In a patient with such a complex medical history, there were several etiologies to consider. The treatment consisted of pericardiectomy and a hybrid technique of supra-aortic debranching and subsequent endovascular stent-graft repair.</p>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Os autores descrevem o caso de um doente do sexo masculino, de 59 anos, hipertenso, ex-fumador, insuficiente renal crónico em hemodiálise, com antecedentes de endoprótese por aneurisma da aorta abdominal e história de tuberculose miliar no passado, a quem é diagnosticado pericardite constritiva e aneurisma da aorta torácica. Num doente com antecedentes patológicos tão diversos, são várias as etiologias a considerar. O tratamento consistiu numa pericardiectomia e numa técnica híbrida de debranching dos ramos supra-aórticos com posterior implantação de endoprótese aórtica.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Carvalho MS, et al. Um caso de pericardite constritiva e aneurisma da aorta torácica: abordagem terapêutica híbrida. Rev Port Cardiol. 2013. <span class="elsevierStyleInterRef" id="intr0005" href="http://dx.doi.org/10.1016/j.repc.2012.08.013">http://dx.doi.org/10.1016/j.repc.2012.08.013</span>.</p>" ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2183 "Ancho" => 1645 "Tamanyo" => 317672 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Transthoracic echocardiogram, showing (A) thickened and echogenic pericardium, and (B) respiratory variation of E-wave amplitude.</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" => 1408 "Ancho" => 1585 "Tamanyo" => 208004 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Thoracic computed tomography angiography, showing a large saccular aneurysm originating in the descending thoracic aorta, distal to the emergence of the left subclavian artery.</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" => 2527 "Ancho" => 1585 "Tamanyo" => 683740 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">(A) Construction of three-branch graft; (B) total debranching of supra-aortic branches (left brachiocephalic, carotid and subclavian arteries).</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" => 1572 "Ancho" => 1585 "Tamanyo" => 256164 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Aortography following endoprosthesis implantation, confirming exclusion of calcified aneurysm (asterisk) from the circulation and patency of the supra-aortic arteries after debranching.</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" => 3212 "Ancho" => 1643 "Tamanyo" => 596012 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Thoracic computed tomography angiography, showing a good result of endoprosthesis implantation (A) and supra-aortic debranching (B).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:24 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pericardial diseases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "E. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 10 | 6 | 16 |
| 2024 October | 48 | 42 | 90 |
| 2024 September | 58 | 27 | 85 |
| 2024 August | 73 | 30 | 103 |
| 2024 July | 66 | 37 | 103 |
| 2024 June | 55 | 23 | 78 |
| 2024 May | 64 | 20 | 84 |
| 2024 April | 54 | 35 | 89 |
| 2024 March | 48 | 22 | 70 |
| 2024 February | 41 | 25 | 66 |
| 2024 January | 42 | 33 | 75 |
| 2023 December | 36 | 37 | 73 |
| 2023 November | 41 | 23 | 64 |
| 2023 October | 42 | 28 | 70 |
| 2023 September | 36 | 29 | 65 |
| 2023 August | 34 | 11 | 45 |
| 2023 July | 28 | 18 | 46 |
| 2023 June | 29 | 14 | 43 |
| 2023 May | 57 | 23 | 80 |
| 2023 April | 26 | 4 | 30 |
| 2023 March | 38 | 22 | 60 |
| 2023 February | 42 | 25 | 67 |
| 2023 January | 27 | 18 | 45 |
| 2022 December | 40 | 19 | 59 |
| 2022 November | 57 | 39 | 96 |
| 2022 October | 40 | 16 | 56 |
| 2022 September | 34 | 39 | 73 |
| 2022 August | 42 | 34 | 76 |
| 2022 July | 41 | 39 | 80 |
| 2022 June | 37 | 19 | 56 |
| 2022 May | 30 | 42 | 72 |
| 2022 April | 49 | 27 | 76 |
| 2022 March | 45 | 37 | 82 |
| 2022 February | 41 | 29 | 70 |
| 2022 January | 30 | 21 | 51 |
| 2021 December | 27 | 28 | 55 |
| 2021 November | 41 | 51 | 92 |
| 2021 October | 54 | 36 | 90 |
| 2021 September | 44 | 30 | 74 |
| 2021 August | 40 | 36 | 76 |
| 2021 July | 22 | 22 | 44 |
| 2021 June | 33 | 18 | 51 |
| 2021 May | 33 | 45 | 78 |
| 2021 April | 34 | 34 | 68 |
| 2021 March | 52 | 24 | 76 |
| 2021 February | 75 | 21 | 96 |
| 2021 January | 37 | 18 | 55 |
| 2020 December | 46 | 3 | 49 |
| 2020 November | 42 | 11 | 53 |
| 2020 October | 31 | 12 | 43 |
| 2020 September | 60 | 8 | 68 |
| 2020 August | 24 | 9 | 33 |
| 2020 July | 59 | 10 | 69 |
| 2020 June | 38 | 7 | 45 |
| 2020 May | 47 | 2 | 49 |
| 2020 April | 37 | 14 | 51 |
| 2020 March | 47 | 8 | 55 |
| 2020 February | 61 | 37 | 98 |
| 2020 January | 48 | 7 | 55 |
| 2019 December | 40 | 12 | 52 |
| 2019 November | 31 | 10 | 41 |
| 2019 October | 54 | 13 | 67 |
| 2019 September | 32 | 9 | 41 |
| 2019 August | 30 | 6 | 36 |
| 2019 July | 36 | 14 | 50 |
| 2019 June | 33 | 23 | 56 |
| 2019 May | 38 | 43 | 81 |
| 2019 April | 35 | 22 | 57 |
| 2019 March | 94 | 16 | 110 |
| 2019 February | 81 | 24 | 105 |
| 2019 January | 99 | 8 | 107 |
| 2018 December | 76 | 23 | 99 |
| 2018 November | 126 | 16 | 142 |
| 2018 October | 289 | 27 | 316 |
| 2018 September | 90 | 13 | 103 |
| 2018 August | 59 | 6 | 65 |
| 2018 July | 46 | 9 | 55 |
| 2018 June | 65 | 7 | 72 |
| 2018 May | 92 | 16 | 108 |
| 2018 April | 84 | 7 | 91 |
| 2018 March | 120 | 11 | 131 |
| 2018 February | 85 | 5 | 90 |
| 2018 January | 126 | 8 | 134 |
| 2017 December | 170 | 7 | 177 |
| 2017 November | 48 | 10 | 58 |
| 2017 October | 32 | 16 | 48 |
| 2017 September | 50 | 10 | 60 |
| 2017 August | 53 | 20 | 73 |
| 2017 July | 47 | 9 | 56 |
| 2017 June | 55 | 5 | 60 |
| 2017 May | 52 | 9 | 61 |
| 2017 April | 40 | 9 | 49 |
| 2017 March | 56 | 77 | 133 |
| 2017 February | 59 | 1 | 60 |
| 2017 January | 55 | 3 | 58 |
| 2016 December | 54 | 15 | 69 |
| 2016 November | 59 | 8 | 67 |
| 2016 October | 69 | 27 | 96 |
| 2016 September | 129 | 10 | 139 |
| 2016 August | 38 | 2 | 40 |
| 2016 July | 25 | 7 | 32 |
| 2016 June | 13 | 9 | 22 |
| 2016 May | 15 | 4 | 19 |
| 2016 April | 24 | 1 | 25 |
| 2016 March | 57 | 25 | 82 |
| 2016 February | 87 | 33 | 120 |
| 2016 January | 71 | 24 | 95 |
| 2015 December | 63 | 22 | 85 |
| 2015 November | 70 | 22 | 92 |
| 2015 October | 96 | 27 | 123 |
| 2015 September | 65 | 24 | 89 |
| 2015 August | 48 | 9 | 57 |
| 2015 July | 106 | 9 | 115 |
| 2015 June | 34 | 5 | 39 |
| 2015 May | 43 | 5 | 48 |
| 2015 April | 59 | 24 | 83 |
| 2015 March | 52 | 20 | 72 |
| 2015 February | 69 | 13 | 82 |
| 2015 January | 57 | 11 | 68 |
| 2014 December | 83 | 13 | 96 |
| 2014 November | 54 | 7 | 61 |
| 2014 October | 64 | 14 | 78 |
| 2014 September | 71 | 22 | 93 |
| 2014 August | 60 | 5 | 65 |
| 2014 July | 62 | 13 | 75 |
| 2014 June | 61 | 4 | 65 |
| 2014 May | 62 | 9 | 71 |
| 2014 April | 60 | 10 | 70 |
| 2014 March | 81 | 22 | 103 |
| 2014 February | 90 | 12 | 102 |
| 2014 January | 81 | 15 | 96 |
| 2013 December | 75 | 9 | 84 |
| 2013 November | 90 | 25 | 115 |
| 2013 October | 99 | 19 | 118 |
| 2013 September | 87 | 22 | 109 |
| 2013 August | 105 | 31 | 136 |
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