Letter to the Editor
Dual chamber permanent pacemaker implantation by femoral approach
Implantação de pacemaker definitivo dupla câmara por via femoral
Gustavo Lima da Silva
, Pedro Marques
Corresponding author
Serviço de Cardiologia, Hospital de Santa Maria, Centro Académico Médico de Lisboa, CCUL, Lisboa, Portugal
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<span class="elsevierStyleItalic">(C)</span> posicionamento e fixação ativa de eletrocateter ventricular no ápex ventricular direito; <span class="elsevierStyleItalic">(D)</span> progressão do eletrocateter auricular bipolar CapSureFix<span class="elsevierStyleSup">®</span> Novus 5076‐85<span class="elsevierStyleHsp" style=""></span>cm (Medtronic Inc., Minneapolis, Minnesota, EUA) através da veia cava inferior; <span class="elsevierStyleItalic">(E)</span> posicionamento e fixação ativa de eletrocateter auricular no apêndice auricular direito; <span class="elsevierStyleItalic">(F)</span><span class="elsevierStyleBold">i</span>mplantação de gerador (<span class="elsevierStyleItalic">Reply D SafeR</span> – <span class="elsevierStyleItalic">Sorin</span> Inc., Milão, Itália) em loca no tecido subcutâneo na fossa ilíaca direita; <span class="elsevierStyleItalic">(G)</span><span class="elsevierStyleBold">f</span>ossa ilíaca direita após sutura de loca.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Gustavo Lima da Silva, Pedro Marques" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Gustavo" "apellidos" => "Lima da Silva" ] 1 => array:2 [ "nombre" => "Pedro" "apellidos" => "Marques" ] ] ] ] ] "idiomaDefecto" => "pt" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2174204915000793" "doi" => "10.1016/j.repce.2014.12.002" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204915000793?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255115000797?idApp=UINPBA00004E" "url" => "/08702551/0000003400000005/v1_201505200240/S0870255115000797/v1_201505200240/pt/main.assets" ] ] "itemSiguiente" => array:20 [ "pii" => "S2174204915000811" "issn" => "21742049" "doi" => "10.1016/j.repce.2015.01.004" "estado" => "S300" "fechaPublicacion" => "2015-05-01" "aid" => "634" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "cor" "cita" => "Rev Port Cardiol. 2015;34:369-70" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2833 "formatos" => array:3 [ "EPUB" => 167 "HTML" => 2136 "PDF" => 530 ] ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Inflammation, systemic lupus erythematosus and the Kounis mast cell activation-associated syndrome" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "369" "paginaFinal" => "370" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Inflamação, lúpus eritematoso sistémico e síndrome de Kounis associada à ativação dos mastócitos" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Nicholas G. 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A Relia SR pacemaker (Medtronic<span class="elsevierStyleSup">®</span>) in VVI mode was implanted, with an 85-cm lead. (A) Site of lead insertion in the femoral vein and position of the generator in the right flank; (B and C) course of the lead up to the apex of the RV; (D) lead positioned in the RV. IVC: inferior vena cava; RV: right ventricle.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Patrícia Rodrigues, Hipólito Reis, Vítor Lagarto, Paulo Palma, Carla Roque, António Pinheiro-Vieira, Diana Anjo, Severo Torres" "autores" => array:8 [ 0 => array:2 [ "nombre" => "Patrícia" "apellidos" => "Rodrigues" ] 1 => array:2 [ "nombre" => "Hipólito" "apellidos" => "Reis" ] 2 => array:2 [ "nombre" => "Vítor" "apellidos" => "Lagarto" ] 3 => array:2 [ "nombre" => "Paulo" "apellidos" => "Palma" ] 4 => array:2 [ "nombre" => "Carla" "apellidos" => "Roque" ] 5 => array:2 [ "nombre" => "António" "apellidos" => "Pinheiro-Vieira" ] 6 => array:2 [ "nombre" => "Diana" "apellidos" => "Anjo" ] 7 => array:2 [ "nombre" => "Severo" "apellidos" => "Torres" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "pt" => array:9 [ "pii" => "S0870255114002261" "doi" => "10.1016/j.repc.2014.05.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "pt" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255114002261?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204914002542?idApp=UINPBA00004E" "url" => "/21742049/0000003300000011/v1_201412120159/S2174204914002542/v1_201412120159/en/main.assets" ] ] "en" => array:16 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Dual chamber permanent pacemaker implantation by femoral approach" "tieneTextoCompleto" => true "saludo" => "To the Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "367" "paginaFinal" => "368" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Gustavo Lima da Silva, Pedro Marques" "autores" => array:2 [ 0 => array:4 [ "nombre" => "Gustavo" "apellidos" => "Lima da Silva" "email" => array:1 [ 0 => "gustavolssilva@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Pedro" "apellidos" => "Marques" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Serviço de Cardiologia, Hospital de Santa Maria, Centro Académico Médico de Lisboa, CCUL, Lisboa, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Implantação de <span class="elsevierStyleItalic">pacemaker</span> definitivo dupla câmara por via femoral" ] ] "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" => 2575 "Ancho" => 3000 "Tamanyo" => 412801 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Incision in the right groin, below the inguinal ligament; (B) advancing the 110-cm CapSureFix<span class="elsevierStyleSup">®</span> Novus 4076 bipolar ventricular lead via the inferior vena cava; (C) positioning and active fixation of the ventricular lead in the right ventricular apex; (D) advancing the 85-cm CapSureFix<span class="elsevierStyleSup">®</span> Novus 5076 bipolar atrial lead via the inferior vena cava; (E) positioning and active fixation of the atrial lead in the right atrial appendage; (F) implantation of the generator in a pocket in the subcutaneous tissue of the right iliac fossa; (G) right groin after suturing of the pocket.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We read with great interest the article by Rodrigues et al., entitled “Permanent pacemaker implantation using a femoral approach”, published in the <span class="elsevierStyleItalic">Journal</span> in November 2014, which described two cases of single-chamber permanent pacemaker (PPM) implantation, in VVI mode, by a femoral approach.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> In the second case, the device was implanted due to symptomatic bradycardia, with intermittent periods of Mobitz II and complete atrioventricular block (AVB), with preserved sinus rhythm. We also note the article by Valente et al., entitled “Femoral approach: an exceptional alternative for permanent pacemaker implantation” published in the <span class="elsevierStyleItalic">Journal</span> in May 2014, which reported a case of single-chamber PPM implantation, in VVIR mode, by a femoral approach, in a patient with symptomatic 2:1 AVB, with preserved sinus rhythm.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a> Most operators are unfamiliar with this technique, although it has been known since the 1980s.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">3,4</span></a> Against this background, we would like to share one of our cases and to comment on the type of device implanted.</p><p id="par0010" class="elsevierStylePara elsevierViewall">An 86-year-old man, with chronic kidney disease and under regular hemodialysis via a left brachiocephalic arteriovenous fistula, had previously had a PPM implanted in right pectoral position for symptomatic intermittent 2:1 AVB; the device was subsequently removed due to infection. A dual-chamber PPM was then implanted via a right femoral approach. An incision was made in the right groin, below the inguinal ligament (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A), followed by a double puncture in the femoral vein. A 110-cm CapSureFix<span class="elsevierStyleSup">®</span> Novus 4076 bipolar ventricular lead and an 85-cm CapSureFix<span class="elsevierStyleSup">®</span> Novus 5076 bipolar atrial lead (Medtronic Inc., Minneapolis, MN, US) were then introduced, advanced and positioned with active fixation in the right ventricular apex and right atrial appendage, respectively (<a class="elsevierStyleCrossRef" href="#fig0005">Figures 1</a>B–E). Excellent wave amplitude and ventricular and atrial pacing thresholds were obtained (impedance 733 Ω, amplitude 7.4 mV, threshold 0.5 mV and impedance 659 Ω, amplitude 0.9 mV, threshold 1 mV, respectively). A pocket was fashioned in the subcutaneous tissue of the right iliac fossa (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>F). The leads were connected to the generator (Reply D in SafeR mode, Sorin Inc., Milan, Italy), which was then implanted in the pocket (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>G), and the device was programmed in DDDR mode. The procedure was uneventful and during two years of follow-up in pacing consultations, the patient was asymptomatic and the system was functioning normally.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">No large-scale randomized clinical trial has shown dual-chamber pacing to be superior to ventricular pacing in patients with AVB in terms of mortality or major morbidity. However, dual-chamber pacing is associated with reduced incidence of pacemaker syndrome, which occurs in 25% of patients with ventricular pacing, and with improved exercise capacity (except compared to VVI-R mode). The 2013 European Society of Cardiology guidelines thus recommend that dual-chamber pacing should be considered in patients with AVB and/or sinus node disease (class IIa recommendation, level of evidence A).<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> In the two most recent series of pacemaker implantation via the femoral vein, the main complication reported was atrial lead dislodgement, in 21% and 20% of cases, respectively.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">6,7</span></a> However, atrial lead dislodgement was reported in only 11% and 0% in the last 19 and 14 implantations of the two series, respectively, suggesting that this complication is related to operator experience.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In conclusion, our center considers the femoral approach to be a valid alternative for PPM implantation when access via the superior vena cava is not possible, and its use should not affect the pacing mode selected for the patient according to international guidelines.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Lima da Silva G, Marques P. Implantação de <span class="elsevierStyleItalic">pacemaker</span> definitivo dupla câmara por via femoral. Rev Port Cardiol. 2015;34:367–368.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2575 "Ancho" => 3000 "Tamanyo" => 412801 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Incision in the right groin, below the inguinal ligament; (B) advancing the 110-cm CapSureFix<span class="elsevierStyleSup">®</span> Novus 4076 bipolar ventricular lead via the inferior vena cava; (C) positioning and active fixation of the ventricular lead in the right ventricular apex; (D) advancing the 85-cm CapSureFix<span class="elsevierStyleSup">®</span> Novus 5076 bipolar atrial lead via the inferior vena cava; (E) positioning and active fixation of the atrial lead in the right atrial appendage; (F) implantation of the generator in a pocket in the subcutaneous tissue of the right iliac fossa; (G) right groin after suturing of the pocket.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Permanent pacemaker implantation using a femoral approach" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "P. Rodrigues" 1 => "H. Reis" 2 => "V. Lagarto" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Rev Port Cardiol" "fecha" => "2014" "volumen" => "33" "paginaInicial" => "733e1" "paginaFinal" => "733e6" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0045" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Femoral approach: an exceptional alternative for permanent pacemaker implantation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "B. Tereno Valente" 1 => "J.M. Conceição" 2 => "M. Nogueira da Silva" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Rev Port Cardiol" "fecha" => "2014" "volumen" => "33" "paginaInicial" => "311e1" "paginaFinal" => "311e5" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0050" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Preliminary experience with the helifix electrode for transvenous atrial implantation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M. El Gamal" 1 => "B. van Gelder" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "PACE" "fecha" => "1979" "volumen" => "2" "paginaInicial" => "444" "paginaFinal" => "454" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/95313" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0055" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Permanent pacemaker implantation using the femoral vein: a preliminary report" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M.H. Ellestad" 1 => "R. Caso" 2 => "P.S. Greenberg" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Clin Electrophysiol" "fecha" => "1980" "volumen" => "3" "paginaInicial" => "418" "paginaFinal" => "423" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0060" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M. Brignole" 1 => "A. Auricchio" 2 => "G. Baron-Esquivias" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/eurheartj/eht150" "Revista" => array:6 [ "tituloSerie" => "Eur Heart J" "fecha" => "2013" "volumen" => "34" "paginaInicial" => "2281" "paginaFinal" => "2329" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23801822" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0065" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Iliac vein approach to permanent pacemaker implantation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M.H. Ellestad" 1 => "J. French" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Pacing Clin Electrophysiol" "fecha" => "1989" "volumen" => "12" "paginaInicial" => "1030" "paginaFinal" => "1033" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2476736" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0070" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Permanent pacemaker implantation via the femoral vein: an alternative in cases with contraindications to the pectoral approach" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "G. Mathur" 1 => "R.H. Stables" 2 => "D. Heaven" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1053/eupc.2000.0135" "Revista" => array:6 [ "tituloSerie" => "Europace" "fecha" => "2001" "volumen" => "3" "paginaInicial" => "56" "paginaFinal" => "59" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11271953" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21742049/0000003400000005/v1_201506091454/S2174204915000793/v1_201506091454/en/main.assets" "Apartado" => array:4 [ "identificador" => "29282" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/file/21742049/0000003400000005/v1_201506091454/S2174204915000793/v1_201506091454/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/&text=false" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204915000793?idApp=UINPBA00004E" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 5 | 12 |
| 2024 October | 41 | 32 | 73 |
| 2024 September | 51 | 26 | 77 |
| 2024 August | 44 | 23 | 67 |
| 2024 July | 50 | 28 | 78 |
| 2024 June | 44 | 24 | 68 |
| 2024 May | 28 | 19 | 47 |
| 2024 April | 23 | 25 | 48 |
| 2024 March | 38 | 16 | 54 |
| 2024 February | 34 | 27 | 61 |
| 2024 January | 30 | 22 | 52 |
| 2023 December | 30 | 24 | 54 |
| 2023 November | 36 | 25 | 61 |
| 2023 October | 28 | 16 | 44 |
| 2023 September | 20 | 20 | 40 |
| 2023 August | 30 | 18 | 48 |
| 2023 July | 24 | 13 | 37 |
| 2023 June | 33 | 12 | 45 |
| 2023 May | 38 | 30 | 68 |
| 2023 April | 28 | 4 | 32 |
| 2023 March | 35 | 22 | 57 |
| 2023 February | 29 | 23 | 52 |
| 2023 January | 37 | 17 | 54 |
| 2022 December | 32 | 24 | 56 |
| 2022 November | 42 | 24 | 66 |
| 2022 October | 37 | 20 | 57 |
| 2022 September | 38 | 40 | 78 |
| 2022 August | 31 | 38 | 69 |
| 2022 July | 47 | 34 | 81 |
| 2022 June | 22 | 23 | 45 |
| 2022 May | 24 | 27 | 51 |
| 2022 April | 38 | 21 | 59 |
| 2022 March | 27 | 25 | 52 |
| 2022 February | 48 | 13 | 61 |
| 2022 January | 43 | 22 | 65 |
| 2021 December | 18 | 26 | 44 |
| 2021 November | 53 | 35 | 88 |
| 2021 October | 46 | 32 | 78 |
| 2021 September | 58 | 24 | 82 |
| 2021 August | 45 | 17 | 62 |
| 2021 July | 35 | 27 | 62 |
| 2021 June | 47 | 16 | 63 |
| 2021 May | 39 | 37 | 76 |
| 2021 April | 64 | 44 | 108 |
| 2021 March | 67 | 23 | 90 |
| 2021 February | 60 | 20 | 80 |
| 2021 January | 35 | 13 | 48 |
| 2020 December | 44 | 8 | 52 |
| 2020 November | 43 | 10 | 53 |
| 2020 October | 32 | 7 | 39 |
| 2020 September | 45 | 8 | 53 |
| 2020 August | 28 | 11 | 39 |
| 2020 July | 72 | 7 | 79 |
| 2020 June | 37 | 6 | 43 |
| 2020 May | 48 | 6 | 54 |
| 2020 April | 38 | 16 | 54 |
| 2020 March | 34 | 6 | 40 |
| 2020 February | 102 | 21 | 123 |
| 2020 January | 33 | 3 | 36 |
| 2019 December | 42 | 8 | 50 |
| 2019 November | 60 | 11 | 71 |
| 2019 October | 29 | 9 | 38 |
| 2019 September | 35 | 9 | 44 |
| 2019 August | 37 | 7 | 44 |
| 2019 July | 38 | 13 | 51 |
| 2019 June | 42 | 6 | 48 |
| 2019 May | 36 | 7 | 43 |
| 2019 April | 36 | 13 | 49 |
| 2019 March | 149 | 8 | 157 |
| 2019 February | 126 | 11 | 137 |
| 2019 January | 105 | 10 | 115 |
| 2018 December | 104 | 8 | 112 |
| 2018 November | 84 | 9 | 93 |
| 2018 October | 163 | 7 | 170 |
| 2018 September | 42 | 16 | 58 |
| 2018 August | 30 | 6 | 36 |
| 2018 July | 35 | 9 | 44 |
| 2018 June | 38 | 4 | 42 |
| 2018 May | 53 | 8 | 61 |
| 2018 April | 67 | 3 | 70 |
| 2018 March | 88 | 6 | 94 |
| 2018 February | 51 | 5 | 56 |
| 2018 January | 58 | 6 | 64 |
| 2017 December | 88 | 6 | 94 |
| 2017 November | 48 | 9 | 57 |
| 2017 October | 39 | 15 | 54 |
| 2017 September | 30 | 19 | 49 |
| 2017 August | 55 | 15 | 70 |
| 2017 July | 52 | 13 | 65 |
| 2017 June | 52 | 6 | 58 |
| 2017 May | 50 | 6 | 56 |
| 2017 April | 26 | 4 | 30 |
| 2017 March | 35 | 31 | 66 |
| 2017 February | 38 | 7 | 45 |
| 2017 January | 42 | 10 | 52 |
| 2016 December | 44 | 9 | 53 |
| 2016 November | 36 | 8 | 44 |
| 2016 October | 20 | 6 | 26 |
| 2016 September | 47 | 10 | 57 |
| 2016 August | 9 | 1 | 10 |
| 2016 July | 20 | 2 | 22 |
| 2016 June | 12 | 3 | 15 |
| 2016 May | 15 | 6 | 21 |
| 2016 April | 32 | 1 | 33 |
| 2016 March | 49 | 16 | 65 |
| 2016 February | 68 | 26 | 94 |
| 2016 January | 51 | 23 | 74 |
| 2015 December | 48 | 18 | 66 |
| 2015 November | 54 | 15 | 69 |
| 2015 October | 62 | 18 | 80 |
| 2015 September | 63 | 17 | 80 |
| 2015 August | 53 | 19 | 72 |
| 2015 July | 53 | 24 | 77 |
| 2015 June | 112 | 63 | 175 |
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