Case report
Giant pseudoaneurysm of the left ventricular outflow tract: A rare disease
Pseudoaneurisma gigante da via de saída do ventrículo esquerdo: uma patologia rara
Larissa Acioli Pereira
, Paula Fontes Gontijo, Jorge Alcântara Farran, Antonio Carlos Palandri Chagas, Edson Renato Romano, Luis Carlos Bento de Souza
Corresponding author
Unidade de Terapia Intensiva, Hospital do Coração de São Paulo – Associação Sanatório Sírio, São Paulo, Brazil
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array:2 [ "entidad" => "Unidade de Terapia Intensiva, Hospital do Coração de São Paulo – Associação Sanatório Sírio, São Paulo, Brazil" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Pseudoaneurisma gigante da via de saída do ventrículo esquerdo: uma patologia rara" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figures 2 and 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2v3.jpeg" "Alto" => 3038 "Ancho" => 1500 "Tamanyo" => 534841 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Chest computed tomography angiography showing a pseudoaneurysm in the left ventricular outflow tract.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0030" class="elsevierStylePara elsevierViewall">A 45-year-old man, an engineer and former intravenous drug user, with chronic hepatitis C, had undergone aortic mechanical valve replacement in May 1998 for infective endocarditis. Seven months later, he developed perivalvular dehiscence and was reoperated for implantation of a prosthetic patch in the ascending aorta. In 2009, he developed persistent atrial fibrillation, and attempts at chemical and electrical cardioversion were unsuccessful.</p><p id="par0035" class="elsevierStylePara elsevierViewall">In 2010, he was admitted to our institution for diagnostic investigation of worsening dry cough, under therapy for pneumonia.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Initial diagnostic exams included simple chest X-ray, which revealed opacity in the base and middle third of the left hemithorax (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>), 12-lead electrocardiogram, which showed atrial fibrillation and left ventricular overload, and laboratory tests, which were normal, with no anemia, leukocytosis or electrolytic changes.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Transesophageal echocardiography revealed left ventricular systolic dysfunction (ejection fraction 38%), moderate left atrial dilatation (50 mm) and significant ascending aortic dilatation (88 mm at its maximum diameter), with an image suggestive of flow between the aortic tube graft and the ascending aorta.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The patient then underwent computed tomography (CT) angiography, which showed a large pseudoaneurysm adjacent to the mitral-aortic intervalvular fibrosa (MAIVF), communicating mainly with the left ventricle (<a class="elsevierStyleCrossRef" href="#fig0010">Figures 2 and 3</a>), and compressing the pulmonary trunk, left pulmonary artery, left main bronchus, and the bronchovascular structures of the lingula and lower lobe of the left lung. There was also deviation of mediastinal structures to the left.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Cine coronary angiography revealed anatomically normal coronary arteries; ventriculography and aortography showed a normal ventricular chamber, with moderate inferolateral hypocontractility and reflux of contrast into a cavity suggestive of a giant pseudoaneurysm communicating with the left ventricle, with calcified walls but not obstructing ventricular ejection.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The patient remained hemodynamically stable during this period. Since the pseudoaneurysm was causing significant compression of neighboring structures, with clinical repercussions, the decision was made to intervene surgically.</p><p id="par0065" class="elsevierStylePara elsevierViewall">On October 5, 2010, the patient underwent cardiovascular surgery with extracorporeal circulation (ECC) and hypothermia at 23<span class="elsevierStyleHsp" style=""></span>°C, with hyperkalemic blood cardioplegia at 5<span class="elsevierStyleHsp" style=""></span>°C injected into the coronary ostia after aortic cross-clamping. When the aortic prosthesis was removed, an orifice approximately 1.5 cm in diameter was revealed (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 4</a>), which was closed with a Dacron patch and a new 23-mm St. Jude aortic mechanical valve was implanted (<a class="elsevierStyleCrossRef" href="#fig0020">Figures 5 and 6</a>), followed by suturing of the aorta and re-warming to 37<span class="elsevierStyleHsp" style=""></span>°C. The patient repeatedly developed ventricular fibrillation, requiring several 20-J shocks, and remained hemodynamically unstable, with significant hypocontractility and considerable difficulty in weaning from ECC. Venous infusion of noradrenaline and vasopressin was begun to maintain blood pressure levels.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Maximum doses of vasoactive drugs were required in the intensive care unit, and intra-aortic balloon pumping and monitoring by Swan-Ganz catheter were performed. The patient developed systemic inflammatory response syndrome, with hyperthermia, coagulopathy, and liver and kidney failure. On the third post-operative day, he was clinically stable; antibiotic therapy was increased and sedation discontinued. However, the following day, the patient was found to be neurologically unresponsive, and brain death was confirmed on October 11, 2010.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0075" class="elsevierStylePara elsevierViewall">Pseudoaneurysm of the left ventricular outflow tract (LVOT) is a rare but highly lethal complication. It was first described in 1969 by Lewis et al.,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> who reported three cases of impending rupture in an autopsy series of 1228 patients with myocardial infarction (MI). In 1988, Savage et al. reported a case diagnosed antemortem, which was successfully treated, and coined the term pseudoaneurysm.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Its precise incidence is unknown, but it is even less common than cardiac rupture after MI, which has an incidence of 2–4%.</p><p id="par0080" class="elsevierStylePara elsevierViewall">LVOT pseudoaneurysm arises from incomplete myocardial rupture, the cavity being surrounded by cardiac muscle and remaining intact due to adhering pericardium or scar tissue in the left ventricular free wall. It mainly occurs after MI, but also following chest trauma, cardiac surgery (a third of cases)<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> or infective endocarditis; it may also be due to congenital heart disease. Areas subjected to surgical manipulation are particularly vulnerable, due to dehiscence in the MAIVF.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> Its incidence is higher (although not significantly) in patients who have undergone aortic valve reoperation, compared to those operated only once (83% and 58%, respectively).</p><p id="par0085" class="elsevierStylePara elsevierViewall">Valve endocarditis is the most common cause of dehiscence in the MAIVF and pseudoaneurysm formation. The fact that this region is poorly vascularized makes it more susceptible to infection. Contamination occurs either through contact with the aortic wall or through dissemination by the regurgitant jet to subaortic structures and the mitral valve anterior leaflet.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Congestive heart failure is the most common clinical manifestation, followed by chest pain, dyspnea and hemoptysis; in some cases sudden death can be the first symptom. Patients are asymptomatic at diagnosis in 12% of cases.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Once formed, a pseudoaneurysm begins to exert additional stress on the aortic wall, which can lead to rupture. Rupture into the pericardium can cause cardiac tamponade, an eccentric mitral regurgitant jet tends to form in the atrium, and in the aorta a fistula occurs communicating with the ventricular chamber, all of which are associated with high morbidity and mortality. Pseudoaneurysms also predispose to embolization and infection. In some cases, the lesion remains intact and becomes chronic, appearing as a pulsatile cavity that expands in systole. There have also been reports of compression of the coronary arteries, causing ischemic symptoms; in these patients, the most common cause of death is heart failure or coronary disease, rather than myocardial rupture.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Diagnostic methods include echocardiography, catheterization, CT, magnetic resonance imaging and angiography; while the latter is the gold standard exam, it is invasive and more costly.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Three-dimensional echocardiography can also be used, although there are few studies on its efficacy in the diagnosis of pseudoaneurysms and their complications.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Since pseudoaneurysms are associated with high morbidity and mortality, with a high risk of serious and potentially fatal complications, most studies recommend surgical repair,<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,7–9</span></a> without which the survival rate is low.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Surgical mortality is now acceptable at 7–23% following technical advances, although there have been reports of spontaneous resolution of pseudoaneurysms.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> In clinically stable patients with chronic pseudoaneurysms of more than three months’ duration, some authors suggest non-invasive treatment with frequent follow-up, which reduces the risk of complications and mortality. Surgical intervention in these patients is recommended in the presence of complications such as tachyarrhythmia or recurrent embolism, if surgery is indicated for another reason, or when the diagnosis is made within three months of MI.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">We present a case of giant pseudoaneurysm of the LVOT, detected 12 years after aortic valve replacement for infective endocarditis in a young patient, a former intravenous drug user. As it is an uncommon disease, with few cases reported in the literature, little is known about its clinical presentation and treatment.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:2 [ "identificador" => "xres247123" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec234413" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres247122" "titulo" => "Resumo" ] 3 => array:2 [ "identificador" => "xpalclavsec234412" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-08-25" "fechaAceptado" => "2012-11-06" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec234413" "palabras" => array:4 [ 0 => "Pseudoaneurysm" 1 => "Infective endocarditis" 2 => "Left ventricular outflow tract" 3 => "Mitral-aortic intervalvular fibrosa" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec234412" "palabras" => array:4 [ 0 => "Pseudoaneurisma" 1 => "Endocardite infecciosa" 2 => "Via de saída do ventrículo esquerdo" 3 => "Anel fibroso mitroaórtico" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pseudoaneurysm of the left ventricular outflow tract (LVOT) is a rare disease with high morbidity and mortality, resulting from left ventricular damage due to myocardial infarction, infective endocarditis or surgical trauma. A case of giant pseudoaneurysm of the LVOT, even more rarely reported in the literature, is described. The lesion was detected 12 years after aortic valve replacement for infective endocarditis in a young patient, a former intravenous drug user. As it is an uncommon disease, little is known about its clinical presentation and treatment.</p>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">O pseudoaneurisma da via de saída do ventrículo esquerdo (VSVE) é uma patologia rara decorrente de agressões sofridas pelo ventrículo esquerdo, como infarto agudo do miocárdio, endocardite infecciosa ou trauma cirúrgico, sendo uma afeção de alta morbimortalidade. Descreve-se um caso de pseudoaneurisma de VSVE gigante ainda mais raramente relatado na literatura. A lesão foi detetada 12 anos após a troca da válvula aórtica por endocardite infecciosa, num paciente jovem e ex-toxicodependente. Por ser uma patologia incomum, pouco se sabe sobre a sua apresentação clínica e respetivo tratamento.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Acioli Pereira L, et al. Pseudoaneurisma gigante da via de saída do ventrículo esquerdo: uma patologia rara. Rev Port Cardiol. 2013. <span class="elsevierStyleInterRef" id="intr0005" href="doi:10.1016/j.repc.2012.11.006">http://dx.doi.org/10.1016/j.repc.2012.11.006</span></p>" ] ] "nomenclatura" => array:1 [ 0 => array:3 [ "identificador" => "nom0005" "titulo" => "<span class="elsevierStyleSectionTitle" id="sect0025">Abbreviations</span>" "listaDefinicion" => array:1 [ 0 => array:1 [ "definicion" => array:5 [ 0 => array:2 [ "termino" => "CT" "descripcion" => "<p id="par0005" class="elsevierStylePara elsevierViewall">computed tomography</p>" ] 1 => array:2 [ "termino" => "ECC" "descripcion" => "<p id="par0010" class="elsevierStylePara elsevierViewall">extracorporeal circulation</p>" ] 2 => array:2 [ "termino" => "LVOT" "descripcion" => "<p id="par0015" class="elsevierStylePara elsevierViewall">left ventricular outflow tract</p>" ] 3 => array:2 [ "termino" => "MAIVF" "descripcion" => "<p id="par0020" class="elsevierStylePara elsevierViewall">mitral-aortic intervalvular fibrosa</p>" ] 4 => array:2 [ "termino" => "MI" "descripcion" => "<p id="par0025" class="elsevierStylePara elsevierViewall">myocardial infarction</p>" ] ] ] ] ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1193 "Ancho" => 1500 "Tamanyo" => 83413 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Chest X-ray showing opacity in the base and middle third of the left hemithorax, with calcified contours. An area of oligemia can be seen in the left upper third of the pulmonary parenchyma, with interstitial infiltrate on the right.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figures 2 and 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2v3.jpeg" "Alto" => 3038 "Ancho" => 1500 "Tamanyo" => 534841 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Chest computed tomography angiography showing a pseudoaneurysm in the left ventricular outflow tract.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1005 "Ancho" => 1500 "Tamanyo" => 190345 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The orifice of the pseudoaneurysm communicating with the left ventricle visualized after removal of the aortic prosthesis.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figures 5 and 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5v6.jpeg" "Alto" => 2027 "Ancho" => 1500 "Tamanyo" => 434715 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Occlusion of the pseudoaneurysm orifice with a Dacron patch.</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" => "Clinical and pathologic features of postinfarction cardiac rupture" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A.J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 10 | 3 | 13 |
| 2024 October | 46 | 43 | 89 |
| 2024 September | 74 | 28 | 102 |
| 2024 August | 47 | 29 | 76 |
| 2024 July | 45 | 33 | 78 |
| 2024 June | 47 | 37 | 84 |
| 2024 May | 61 | 20 | 81 |
| 2024 April | 41 | 43 | 84 |
| 2024 March | 43 | 29 | 72 |
| 2024 February | 38 | 29 | 67 |
| 2024 January | 48 | 25 | 73 |
| 2023 December | 40 | 40 | 80 |
| 2023 November | 48 | 24 | 72 |
| 2023 October | 53 | 22 | 75 |
| 2023 September | 35 | 24 | 59 |
| 2023 August | 39 | 19 | 58 |
| 2023 July | 30 | 18 | 48 |
| 2023 June | 40 | 23 | 63 |
| 2023 May | 57 | 27 | 84 |
| 2023 April | 46 | 5 | 51 |
| 2023 March | 42 | 27 | 69 |
| 2023 February | 44 | 25 | 69 |
| 2023 January | 50 | 20 | 70 |
| 2022 December | 35 | 23 | 58 |
| 2022 November | 58 | 36 | 94 |
| 2022 October | 34 | 18 | 52 |
| 2022 September | 30 | 42 | 72 |
| 2022 August | 40 | 33 | 73 |
| 2022 July | 38 | 43 | 81 |
| 2022 June | 31 | 26 | 57 |
| 2022 May | 36 | 34 | 70 |
| 2022 April | 42 | 33 | 75 |
| 2022 March | 26 | 31 | 57 |
| 2022 February | 42 | 19 | 61 |
| 2022 January | 39 | 21 | 60 |
| 2021 December | 27 | 28 | 55 |
| 2021 November | 48 | 56 | 104 |
| 2021 October | 51 | 54 | 105 |
| 2021 September | 40 | 32 | 72 |
| 2021 August | 53 | 40 | 93 |
| 2021 July | 25 | 29 | 54 |
| 2021 June | 34 | 34 | 68 |
| 2021 May | 30 | 42 | 72 |
| 2021 April | 43 | 51 | 94 |
| 2021 March | 71 | 27 | 98 |
| 2021 February | 49 | 18 | 67 |
| 2021 January | 36 | 15 | 51 |
| 2020 December | 35 | 14 | 49 |
| 2020 November | 52 | 17 | 69 |
| 2020 October | 31 | 15 | 46 |
| 2020 September | 55 | 19 | 74 |
| 2020 August | 26 | 9 | 35 |
| 2020 July | 54 | 14 | 68 |
| 2020 June | 47 | 11 | 58 |
| 2020 May | 40 | 11 | 51 |
| 2020 April | 36 | 12 | 48 |
| 2020 March | 48 | 19 | 67 |
| 2020 February | 78 | 31 | 109 |
| 2020 January | 36 | 11 | 47 |
| 2019 December | 34 | 11 | 45 |
| 2019 November | 25 | 4 | 29 |
| 2019 October | 49 | 14 | 63 |
| 2019 September | 67 | 8 | 75 |
| 2019 August | 31 | 8 | 39 |
| 2019 July | 45 | 9 | 54 |
| 2019 June | 19 | 12 | 31 |
| 2019 May | 55 | 25 | 80 |
| 2019 April | 30 | 24 | 54 |
| 2019 March | 91 | 19 | 110 |
| 2019 February | 80 | 21 | 101 |
| 2019 January | 86 | 11 | 97 |
| 2018 December | 87 | 24 | 111 |
| 2018 November | 117 | 23 | 140 |
| 2018 October | 174 | 31 | 205 |
| 2018 September | 30 | 12 | 42 |
| 2018 August | 64 | 16 | 80 |
| 2018 July | 39 | 5 | 44 |
| 2018 June | 37 | 4 | 41 |
| 2018 May | 65 | 5 | 70 |
| 2018 April | 45 | 6 | 51 |
| 2018 March | 68 | 7 | 75 |
| 2018 February | 40 | 13 | 53 |
| 2018 January | 64 | 10 | 74 |
| 2017 December | 90 | 8 | 98 |
| 2017 November | 47 | 10 | 57 |
| 2017 October | 36 | 6 | 42 |
| 2017 September | 42 | 4 | 46 |
| 2017 August | 33 | 14 | 47 |
| 2017 July | 26 | 11 | 37 |
| 2017 June | 41 | 5 | 46 |
| 2017 May | 54 | 23 | 77 |
| 2017 April | 35 | 11 | 46 |
| 2017 March | 47 | 40 | 87 |
| 2017 February | 46 | 9 | 55 |
| 2017 January | 47 | 2 | 49 |
| 2016 December | 64 | 11 | 75 |
| 2016 November | 30 | 5 | 35 |
| 2016 October | 47 | 4 | 51 |
| 2016 September | 41 | 6 | 47 |
| 2016 August | 15 | 4 | 19 |
| 2016 July | 23 | 3 | 26 |
| 2016 June | 24 | 3 | 27 |
| 2016 May | 30 | 3 | 33 |
| 2016 April | 33 | 1 | 34 |
| 2016 March | 53 | 19 | 72 |
| 2016 February | 78 | 23 | 101 |
| 2016 January | 61 | 21 | 82 |
| 2015 December | 48 | 17 | 65 |
| 2015 November | 58 | 14 | 72 |
| 2015 October | 82 | 22 | 104 |
| 2015 September | 62 | 15 | 77 |
| 2015 August | 57 | 10 | 67 |
| 2015 July | 49 | 4 | 53 |
| 2015 June | 35 | 2 | 37 |
| 2015 May | 45 | 8 | 53 |
| 2015 April | 42 | 14 | 56 |
| 2015 March | 44 | 15 | 59 |
| 2015 February | 45 | 8 | 53 |
| 2015 January | 50 | 7 | 57 |
| 2014 December | 51 | 11 | 62 |
| 2014 November | 41 | 8 | 49 |
| 2014 October | 55 | 10 | 65 |
| 2014 September | 54 | 11 | 65 |
| 2014 August | 39 | 12 | 51 |
| 2014 July | 49 | 12 | 61 |
| 2014 June | 81 | 7 | 88 |
| 2014 May | 71 | 11 | 82 |
| 2014 April | 59 | 16 | 75 |
| 2014 March | 91 | 20 | 111 |
| 2014 February | 96 | 10 | 106 |
| 2014 January | 103 | 18 | 121 |
| 2013 December | 72 | 15 | 87 |
| 2013 November | 105 | 15 | 120 |
| 2013 October | 81 | 22 | 103 |
| 2013 September | 82 | 20 | 102 |
| 2013 August | 93 | 31 | 124 |
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