Case Report
Acute coronary syndrome of paradoxical origin
Síndrome coronária aguda de origem paradoxal
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type II perforation showing limited extravasation with some myocardial blushing (B); no myocardial blushing is seen on the control angiogram after covered stenting (C).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Ismail Dogu Kilic, Yusuf Izzettin Alihanoglu, Serhat B. Yildiz, Ozgur Taskoylu, Mustafa Zungur, Ihsan S. Uyar, Harun Evrengul" "autores" => array:7 [ 0 => array:2 [ "nombre" => "Ismail Dogu" "apellidos" => "Kilic" ] 1 => array:2 [ "nombre" => "Yusuf Izzettin" "apellidos" => "Alihanoglu" ] 2 => array:2 [ "nombre" => "Serhat B." "apellidos" => "Yildiz" ] 3 => array:2 [ "nombre" => "Ozgur" "apellidos" => "Taskoylu" ] 4 => array:2 [ "nombre" => "Mustafa" "apellidos" => "Zungur" ] 5 => array:2 [ "nombre" => "Ihsan S." "apellidos" => "Uyar" ] 6 => array:2 [ "nombre" => "Harun" "apellidos" => "Evrengul" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204913002304?idApp=UINPBA00004E" "url" => "/21742049/0000003200000010/v1_201312121254/S2174204913002304/v1_201312121254/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case Report</span>" "titulo" => "Acute coronary syndrome of paradoxical origin" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "817" "paginaFinal" => "821" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Ana Rita Ferreira, António Freitas, Pedro Magno, Ana Oliveira Soares, Pedro Farto e Abreu, José Pedro Neves, Victor M. Gil" "autores" => array:7 [ 0 => array:4 [ "nombre" => "Ana Rita" "apellidos" => "Ferreira" "email" => array:1 [ 0 => "aritaf@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" => "António" "apellidos" => "Freitas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Pedro" "apellidos" => "Magno" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Ana" "apellidos" => "Oliveira Soares" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Pedro" "apellidos" => "Farto e Abreu" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "José Pedro" "apellidos" => "Neves" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 6 => array:3 [ "nombre" => "Victor M." "apellidos" => "Gil" "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 Fernando da Fonseca, Amadora, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Serviço de Cirurgia Cardiotorácica, Centro Hospitalar de Lisboa Ocidental, Hospital de Santa Cruz, Carnaxide, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Síndrome coronária aguda de origem paradoxal" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 870 "Ancho" => 1668 "Tamanyo" => 203659 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">12-lead electrocardiogram with ST-segment elevation in leads II, III, aVF, V5 and V6.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Paradoxical embolism is an uncommon situation, accounting for less than 2% of all arterial emboli.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> We describe a rare case of acute myocardial infarction secondary to paradoxical embolism complicating acute pulmonary embolism.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 44-year-old woman, taking oral contraceptives, with a medical history of type 2 diabetes and mild obesity, presented with an acute episode of non-radiating substernal chest pain, which aroused her from sleep. She also suffered dyspnea, nausea, diaphoresis and transient loss of consciousness before reaching the emergency department two and a half hours later. Her vital signs were blood pressure 120/80 mmHg, heart rate 85 beats per minute, respiratory rate 23 cycles per minute and oxygen saturation 75% in room air. The remainder of the physical examination was unremarkable. The electrocardiogram (ECG) showed sinus rhythm and ST-segment elevation in leads II, III, aVF, V5 and V6 (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). She was diagnosed with acute inferior ST-elevation myocardial infarction (MI) and was admitted to the coronary care unit (CCU).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">In the CCU screening transthoracic echocardiography excluded mechanical complications of MI and showed a non-dilated left ventricle, with good global systolic function, akinesia of the inferior wall and dilatation of the right cardiac chambers. In view of a possible inferior MI with extension to the right ventricle, the patient underwent emergency coronary angiography that confirmed an occlusion (TIMI flow 0) of the distal right coronary artery (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>A). The other coronary arteries were normal. An Export® aspiration catheter (Medtronic, Minneapolis, USA) was advanced into the right coronary artery and multiple thrombi were aspirated. After thrombectomy, TIMI flow 3 was documented, but residual stenosis was noted in the distal right coronary artery and a bare-metal stent was implanted (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>B).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">On return to the CCU, the patient experienced complete relief of chest pain and ST-segment normalization on the ECG. Nonetheless, her oxygen saturation level was still 90% despite high-flow oxygen by mask. A full transthoracic echocardiogram examination was then performed. A mass consistent with a thrombus was noted in the left atrium, appearing to arise from a redundant interatrial septum, while the right ventricle was moderately dilated with positive McConnell sign and the interventricular septum was displaced into the left ventricle, which was D-shaped in short-axis view (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>). The pulmonary artery was dilated and the flow across the pulmonary valve suggested severe pulmonary hypertension with pulmonary artery systolic pressure estimated at 70 mmHg. In apical 4-chamber view, color flow imaging of the interatrial septum showed a right-to-left shunt. It was then decided to perform transesophageal echocardiography (TEE) to better characterize the relationship of the mass with the interatrial septum and its embolic potential, and also to look for masses in the right atrium. TTE showed a long thrombus that appeared to be attached to the atrial septum in the region of the foramen ovale. Color flow imaging was consistent with a patent foramen ovale (PFO) and the atrial septum was aneurysmatic. The thrombus had a snake-like movement inside the left atrium and its distal end was freely mobile, prolapsing through the mitral valve (<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>). No mass was observed in the right atrium or pulmonary arteries. Thoracic computed tomography angiography revealed bilateral thrombi in the main and lobar branches of the pulmonary artery (<a class="elsevierStyleCrossRef" href="#fig0025">Figure 5</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">According to the criteria suggested by Johnson,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> the patient had a definitive diagnosis of paradoxical embolism: a thrombus crossing an intracardiac defect was seen during echocardiography in the presence of an arterial embolus. The therapeutic options for paradoxical embolism are still a matter of debate. In our case, cardiothoracic surgeons were consulted and considered the operative risk to be too high, and the patient did not consent to surgical intervention. Due to her stable clinical condition and the absence of neurological signs, we decided to maintain her on full-dose anticoagulation with enoxaparin and double antiplatelet therapy. Venous Doppler echocardiography of the lower limbs was normal. Five days later the transthoracic echocardiogram was repeated; no reduction was noted in the size of the left atrial thrombus, whereupon the cardiothoracic surgeons were again consulted and it was decided to operate. The same day, she was transferred to a surgical center and surgery was performed: an atrial aspiration system was placed in the right superior pulmonary vein, the right atrium and the interatrial septum were opened and the left atrium was inspected. No thrombus was seen in any cardiac chamber or vessel and the PFO was sutured. The patient's postoperative course was remarkably stable and the transthoracic echocardiogram before hospital discharge showed no signs of right ventricular overload. She was discharged home anticoagulated with warfarin and advised to discontinue oral contraceptives. Further laboratory testing showed no thrombophilia status.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">As proposed by Johnson, the diagnosis of paradoxical embolism can be: 1) definitive – when made at autopsy or when a thrombus is seen crossing an intracardiac defect during echocardiography in the presence of an arterial embolus; 2) presumptive – when there is systemic arterial embolus in the absence of a left-sided cardiac or proximal arterial source plus a right-to-left shunt at some level plus venous thrombosis and/or pulmonary embolus; 3) possible – only arterial embolus and PFO detected.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In our patient we had a definitive diagnosis of paradoxical embolism, as noted above. Although in situ thrombus formation over a ruptured plaque cannot be definitively excluded in our patient, the angiographic appearance of the thrombus was most consistent with coronary embolization. The patient's increased risk of venous thrombosis can be explained by oral contraceptive use. An interesting point is that when the left atrium was opened during surgery no thrombus was seen, even though the transthoracic echocardiogram on the same day had shown no reduction in the size of the mass. The most probable explanation is aspiration of the mass by the atrial aspiration system put in place before the left atrium was opened.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Most cases of paradoxical embolism have been associated with PFO.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> Although PFO is a frequent finding in the general population, paradoxical embolism is an uncommon event.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> Paradoxical embolism in a coronary artery is a recognized clinical entity, but is rare and usually definitively established only at autopsy.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> Impending paradoxical embolism, in which a thrombus is seen straddling an interatrial defect, is also a rare diagnosis. Finally, paradoxical embolism with coronary embolization and visualization of the thrombus crossing a PFO is even rarer, with very few cases described in the literature.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,6–9</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The vast majority of patients with paradoxical embolism present with symptoms of pulmonary embolism (82%) or arterial embolism (25%). Only 16% of patients present with findings suggestive of both venous and arterial embolism.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Pulmonary embolism (or any condition that raises right atrial pressure) is frequently implicated in the increased right heart pressures that set the stage for right-to-left shunting via a PFO.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,7,9</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">TEE is crucial for accurate diagnosis and appropriate management when paradoxical embolism is suspected.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> TEE study with color Doppler and contrast echocardiography is the most sensitive diagnostic technique for diagnosing PFO.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> The four cases described in the literature of antemortem diagnosis of paradoxical coronary embolism with visualization of a thrombus crossing a PFO used TEE to establish the diagnosis. TEE is the ideal diagnostic procedure in the setting of suspected myocardial infarction of thromboembolic origin because of its ability to visualize both paradoxical emboli and the proximal portions of the coronary arteries.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,6,7</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Mortality in paradoxical embolism with entrapped embolus is estimated at 21%.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The treatment of paradoxical or impending paradoxical embolism is a clinical dilemma. Acute treatment options include anticoagulation, fibrinolysis or surgical embolectomy. In the presence of a thrombus with a high embolic potential, fibrinolysis carries a high risk of fragmentation and systemic embolization.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,10</span></a> In the setting of a thrombus crossing a PFO, thrombolytic therapy has the potential to result in systemic embolization and devastating neurological complications. Surgery also enables simultaneous closure of the PFO.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7,10</span></a> Overall survival appears to be equivalent among the three therapeutic options, although more complications relating to arterial and pulmonary embolization occur with anticoagulation and fibrinolysis. For this reason, anticoagulation followed by surgical embolectomy has been recommended as the optimal therapy, although recommendations for the management of paradoxical embolism are based on small series and isolated case reports. A medical strategy using thrombolytic therapy or heparin therapy alone may have a role in patients at increased surgical risk.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:2 [ "identificador" => "xres298791" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec281814" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres298790" "titulo" => "Resumo" ] 3 => array:2 [ "identificador" => "xpalclavsec281815" "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:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2010-09-08" "fechaAceptado" => "2013-07-04" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec281814" "palabras" => array:3 [ 0 => "Paradoxical embolism" 1 => "Patent foramen ovale" 2 => "Myocardial infarction" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec281815" "palabras" => array:3 [ 0 => "Embolia paradoxal" 1 => "<span class="elsevierStyleItalic">Foramen ovale</span> patente" 2 => "Enfarte do miocárdio" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">We describe a rare case of acute myocardial infarction secondary to paradoxical embolism complicating acute pulmonary embolism. A 44-year-old woman presented to the emergency department with chest pain. The physical examination was unremarkable except for oxygen saturation of 75%, and the electrocardiogram showed ST-segment elevation in the inferior leads. Urgent coronary angiography showed a distal occlusion of the right coronary artery and multiple thrombi were aspirated. Despite relief of chest pain and electrocardiogram normalization, her oxygen saturation remained low (90%) with high-flow oxygen by mask. The transthoracic echocardiogram showed a mass in the left atrium and dilatation of the right chambers, while the transesophageal echocardiogram showed a thrombus attached to the interatrial septum in the region of the foramen ovale. Color flow imaging was consistent with a patent foramen ovale. Thoracic computed tomography angiography documented thrombi in both branches of the pulmonary trunk. After five days on anticoagulation, the patient underwent surgical foramen ovale closure.</p>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Descreve-se um caso raro de enfarte agudo do miocárdio por embolia paradoxal em contexto de tromboembolismo pulmonar agudo. Uma mulher de 44 anos recorreu à urgência por dor torácica. A observação foi normal com exceção de saturação periférica de 75%. O electrocardiograma mostrou supradesnivelamento do segmento ST nas derivações inferiores. Realizou-se cateterismo urgente que mostrou coronária direita ocluída distalmente, tendo sido aspirados múltiplos trombos. Verificou-se alívio da dor e desaparecimento do supradesnivelamento de ST. No entanto, a saturação periférica mantinha-se baixa apesar de aporte com oxigénio. O ecocardiograma transtorácico mostrou massa auricular esquerda e dilatação das cavidades direitas. O ecocardiograma transesofágico revelou um trombo no septo interauricular, na região do <span class="elsevierStyleItalic">foramen ovale</span>. O estudo por Doppler-cor foi compatível com <span class="elsevierStyleItalic">foramen ovale</span> patente. A angio-tomografia computorizada do tórax documentou trombos nos ramos principais da artéria pulmonar. Após cinco dias de anticoagulação a doente foi submetida a cirurgia cardíaca e o <span class="elsevierStyleItalic">foramen ovale</span> encerrado.</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" => 870 "Ancho" => 1668 "Tamanyo" => 203659 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">12-lead electrocardiogram with ST-segment elevation in leads II, III, aVF, V5 and V6.</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" => 717 "Ancho" => 1665 "Tamanyo" => 98682 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">(A) Coronary angiography showing distal occlusion of the right coronary artery; (B) final result after thrombus aspiration and stent implantation.</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" => 2154 "Ancho" => 2500 "Tamanyo" => 366277 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">(A) parasternal long-axis view; (B) parasternal short-axis view of the aortic valve; (C) zoom of short-axis view; (D) D-shaped left ventricle. Ao: aorta; IVS: interventricular septum; LA: left atrium; LV: left ventricle; RA: right atrium; RV: right ventricle; RVOT: right ventricular outflow tract; Tr: thrombus.</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" => 866 "Ancho" => 2334 "Tamanyo" => 115338 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiogram showing thrombus crossing the interatrial septum. LA: left atrium; LV: left ventricle; RA: right atrium; RV: right ventricle; Tr: thrombus.</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" => 1134 "Ancho" => 1336 "Tamanyo" => 186939 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Thoracic computed tomography angiography showing bilateral thrombi in the main branches of the pulmonary artery.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paradoxical embolism" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "B.I. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 11 | 6 | 17 |
| 2024 October | 46 | 34 | 80 |
| 2024 September | 63 | 35 | 98 |
| 2024 August | 49 | 35 | 84 |
| 2024 July | 41 | 33 | 74 |
| 2024 June | 47 | 23 | 70 |
| 2024 May | 62 | 20 | 82 |
| 2024 April | 35 | 23 | 58 |
| 2024 March | 47 | 19 | 66 |
| 2024 February | 35 | 21 | 56 |
| 2024 January | 56 | 22 | 78 |
| 2023 December | 30 | 20 | 50 |
| 2023 November | 43 | 23 | 66 |
| 2023 October | 36 | 17 | 53 |
| 2023 September | 27 | 18 | 45 |
| 2023 August | 23 | 11 | 34 |
| 2023 July | 28 | 10 | 38 |
| 2023 June | 32 | 11 | 43 |
| 2023 May | 36 | 26 | 62 |
| 2023 April | 29 | 6 | 35 |
| 2023 March | 29 | 25 | 54 |
| 2023 February | 32 | 14 | 46 |
| 2023 January | 41 | 18 | 59 |
| 2022 December | 32 | 20 | 52 |
| 2022 November | 41 | 26 | 67 |
| 2022 October | 33 | 14 | 47 |
| 2022 September | 63 | 31 | 94 |
| 2022 August | 110 | 21 | 131 |
| 2022 July | 66 | 33 | 99 |
| 2022 June | 70 | 27 | 97 |
| 2022 May | 31 | 23 | 54 |
| 2022 April | 33 | 33 | 66 |
| 2022 March | 37 | 32 | 69 |
| 2022 February | 46 | 27 | 73 |
| 2022 January | 51 | 26 | 77 |
| 2021 December | 42 | 29 | 71 |
| 2021 November | 52 | 36 | 88 |
| 2021 October | 63 | 36 | 99 |
| 2021 September | 36 | 28 | 64 |
| 2021 August | 42 | 21 | 63 |
| 2021 July | 34 | 25 | 59 |
| 2021 June | 34 | 17 | 51 |
| 2021 May | 33 | 34 | 67 |
| 2021 April | 66 | 40 | 106 |
| 2021 March | 66 | 16 | 82 |
| 2021 February | 48 | 20 | 68 |
| 2021 January | 32 | 9 | 41 |
| 2020 December | 28 | 8 | 36 |
| 2020 November | 24 | 12 | 36 |
| 2020 October | 13 | 10 | 23 |
| 2020 September | 52 | 5 | 57 |
| 2020 August | 25 | 6 | 31 |
| 2020 July | 54 | 10 | 64 |
| 2020 June | 33 | 3 | 36 |
| 2020 May | 41 | 5 | 46 |
| 2020 April | 54 | 14 | 68 |
| 2020 March | 43 | 11 | 54 |
| 2020 February | 57 | 14 | 71 |
| 2020 January | 43 | 5 | 48 |
| 2019 December | 33 | 7 | 40 |
| 2019 November | 32 | 3 | 35 |
| 2019 October | 35 | 9 | 44 |
| 2019 September | 14 | 10 | 24 |
| 2019 August | 21 | 7 | 28 |
| 2019 July | 34 | 15 | 49 |
| 2019 June | 33 | 5 | 38 |
| 2019 May | 38 | 7 | 45 |
| 2019 April | 23 | 14 | 37 |
| 2019 March | 83 | 8 | 91 |
| 2019 February | 82 | 10 | 92 |
| 2019 January | 89 | 10 | 99 |
| 2018 December | 76 | 5 | 81 |
| 2018 November | 142 | 12 | 154 |
| 2018 October | 244 | 14 | 258 |
| 2018 September | 73 | 18 | 91 |
| 2018 August | 71 | 5 | 76 |
| 2018 July | 29 | 5 | 34 |
| 2018 June | 38 | 9 | 47 |
| 2018 May | 54 | 5 | 59 |
| 2018 April | 49 | 6 | 55 |
| 2018 March | 61 | 9 | 70 |
| 2018 February | 37 | 7 | 44 |
| 2018 January | 22 | 4 | 26 |
| 2017 December | 48 | 13 | 61 |
| 2017 November | 31 | 8 | 39 |
| 2017 October | 43 | 8 | 51 |
| 2017 September | 28 | 13 | 41 |
| 2017 August | 28 | 10 | 38 |
| 2017 July | 16 | 5 | 21 |
| 2017 June | 42 | 14 | 56 |
| 2017 May | 35 | 7 | 42 |
| 2017 April | 23 | 1 | 24 |
| 2017 March | 55 | 9 | 64 |
| 2017 February | 77 | 1 | 78 |
| 2017 January | 29 | 1 | 30 |
| 2016 December | 59 | 14 | 73 |
| 2016 November | 36 | 5 | 41 |
| 2016 October | 34 | 2 | 36 |
| 2016 September | 31 | 7 | 38 |
| 2016 August | 9 | 1 | 10 |
| 2016 July | 11 | 3 | 14 |
| 2016 June | 11 | 1 | 12 |
| 2016 May | 15 | 3 | 18 |
| 2016 April | 24 | 2 | 26 |
| 2016 March | 40 | 3 | 43 |
| 2016 February | 36 | 11 | 47 |
| 2016 January | 21 | 2 | 23 |
| 2015 December | 20 | 3 | 23 |
| 2015 November | 21 | 5 | 26 |
| 2015 October | 25 | 10 | 35 |
| 2015 September | 26 | 8 | 34 |
| 2015 August | 23 | 6 | 29 |
| 2015 July | 19 | 8 | 27 |
| 2015 June | 10 | 1 | 11 |
| 2015 May | 14 | 7 | 21 |
| 2015 April | 25 | 11 | 36 |
| 2015 March | 17 | 4 | 21 |
| 2015 February | 21 | 2 | 23 |
| 2015 January | 33 | 5 | 38 |
| 2014 December | 29 | 7 | 36 |
| 2014 November | 22 | 4 | 26 |
| 2014 October | 23 | 9 | 32 |
| 2014 September | 36 | 3 | 39 |
| 2014 August | 34 | 4 | 38 |
| 2014 July | 35 | 10 | 45 |
| 2014 June | 26 | 1 | 27 |
| 2014 May | 21 | 13 | 34 |
| 2014 April | 25 | 1 | 26 |
| 2014 March | 29 | 12 | 41 |
| 2014 February | 51 | 10 | 61 |
| 2014 January | 46 | 16 | 62 |
| 2013 December | 13 | 8 | 21 |
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