Case report
Two potentially fatal surprises in the preoperative assessment of an asymptomatic young adult
Duas surpresas potencialmente fatais em avaliação pré-operatória de adulto jovem assintomático
Antonio José Lagoeiro Jorge
, Antonio Alves do Couto, Evandro Tinoco Mesquita, Mario Luiz Ribeiro, Celso Vale de Souza Junior, Wolney de Andrade Martins
Corresponding author
Universidade Federal Fluminense, Niterói, Brazil
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"paginaFinal" => "309.e6" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Antonio José Lagoeiro Jorge, Antonio Alves do Couto, Evandro Tinoco Mesquita, Mario Luiz Ribeiro, Celso Vale de Souza Junior, Wolney de Andrade Martins" "autores" => array:6 [ 0 => array:4 [ "nombre" => "Antonio José" "apellidos" => "Lagoeiro Jorge" "email" => array:1 [ 0 => "lagoeiro@globo.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Antonio Alves" "apellidos" => "do Couto" ] 2 => array:2 [ "nombre" => "Evandro Tinoco" "apellidos" => "Mesquita" ] 3 => array:2 [ "nombre" => "Mario Luiz" "apellidos" => "Ribeiro" ] 4 => array:2 [ "nombre" => "Celso Vale" "apellidos" => "de Souza Junior" ] 5 => array:2 [ "nombre" => "Wolney" "apellidos" => "de Andrade Martins" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Universidade Federal Fluminense, Niterói, Brazil" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Duas surpresas potencialmente fatais em avaliação pré-operatória de adulto jovem assintomático" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 960 "Ancho" => 1604 "Tamanyo" => 311279 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">24-hour Holter ECG monitoring showing an episode of paroxysmal supraventricular tachycardia.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Isolated left ventricular non-compaction (LVNC) was described for the first time by Chin et al. in 1990.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a> It is a rare disease classified as a primary genetic cardiomyopathy by the American Heart Association.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">2</span></a> LVNC is attributed to intrauterine arrest of compaction of the meshwork of the fetal myocardium.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The prevalence of LVNC in the general population is unknown. Existing information is mainly derived from patients undergoing Doppler echocardiography. A Swiss review identified 34 cases, corresponding to 0.014% of all echocardiograms performed over a period of 15 years.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">4</span></a> The prevalence of LVNC in patients with heart failure (HF) has been estimated as 3–4%.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">5</span></a> It appears to affect predominantly males, as shown in the four main series on LVNC patients.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">1,4,6,7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">A family history of LVNC is described in 12–50% of case reports.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">8</span></a> Autosomal dominant inheritance is more common than X-linked or autosomal recessive inheritance.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">9</span></a> There is growing recognition of a considerable overlap in the genetic loci involved in the pathogenesis of the main cardiomyopathies. Phenotypic expression of different cardiomyopathies may be found in the same patient, including LVNC and hypertrophic cardiomyopathy,<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">10</span></a> although LVNC is more commonly associated with congenital heart disease and Wolff-Parkinson-White syndrome.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">11</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Preoperative assessment provides an opportunity for the physician to identify silent conditions and to optimize treatment of known cardiovascular disease. In recent years, in an attempt to avoid wasting resources on unnecessary medical exams, medical societies have established protocols for requests for preoperative exams. An editorial by the Cleveland Clinic,<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">12</span></a> which is in agreement with the II Preoperative Guideline of the Brazilian Society of Cardiology (SBC),<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">13</span></a> questions the value of the electrocardiogram (ECG) in preoperative assessment of asymptomatic individuals scheduled for low-risk surgery.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0025" class="elsevierStylePara elsevierViewall">A 35-year-old man with partial rupture of the left Achilles tendon caused by a sports accident was referred by the surgeon for preoperative assessment. He had no cardiovascular symptoms or history of heart disease, was not taking prescription medication and did not smoke. Physical examination revealed blood pressure of 135/78 mmHg and heart rate of 89 bpm and no relevant alterations. He had a walking boot on his left leg. The chest X-ray was normal, and complete blood panel, blood glucose, plasma creatinine, urea and international normalized ratio were within reference values. The ECG showed complete left bundle branch block (LBBB). Tissue Doppler imaging (TDI) revealed left ventricular (LV) ejection fraction (LVEF) of 61%, left atrial volume index of 22 ml/m<span class="elsevierStyleSup">2</span>, and LV mass index of 94.9 g/m<span class="elsevierStyleSup">2</span>. Alterations in LV relaxation (E′=6 cm/s) and increased filling pressures (E/E′=16) were observed. TDI showed hypertrabeculation of the mid anterolateral wall and apical region (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). As the differential diagnosis of LVNC includes other forms of cardiomyopathy, the patient was referred for computed tomography coronary angiography, which showed signs of bilateral pulmonary embolism (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>). D-dimers were 2310 ng/ml. Doppler echocardiography of the venous system of the left leg demonstrated hypoechogenic material in the popliteal and posterior tibial veins, partially obstructing the lumen. Cardiac magnetic resonance imaging (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>) showed LV hypertrophy and marked mid-apical subendocardial trabeculation (estimated at 22% of total myocardial mass), myocardial late enhancement indicative of mid anteroseptal and basal mid inferoseptal myocardial fibrosis, and moderate global LV dysfunction, with LVEF estimated at 38%, confirming the diagnosis of LVNC.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Outpatient Holter 24-hour electrocardiographic monitoring showed an episode of paroxysmal supraventricular tachycardia and ventricular extrasystoles (<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>), but the patient remained asymptomatic.</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">LVNC is a rare disease characterized by excessive trabeculation of the LV wall and intratrabecular recesses communicating with the LV chamber. In most cases it is diagnosed in infancy, but symptoms may not appear until adulthood. Its incidence is estimated at 0.05% in the adult population.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">2</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">LVNC is usually associated with other congenital heart disease such as atrial and septal defects. Isolated LVNC (in the absence of other congenital defects) is even rarer.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">14</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The diagnostic criteria proposed by Jenni et al.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">15</span></a> are designed to distinguish isolated LVNC from other forms of LV hypertrophy. The criteria are (1) at least four prominent trabecula and deep intertrabecular recesses; (2) blood flow in the recesses demonstrable with color Doppler; (3) the non-compacted segments mainly involve the apex and the inferior and mid portions of the LV wall; (4) the non-compacted segments typically have a two-layer structure with a ratio between the subendocardial non-compacted layer and the subepicardial compacted layer of >2:1; (5) coexisting cardiac abnormalities are absent.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">15</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Diagnosis of LVNC in adults is challenging due to its similarity to more common conditions such as dilated hypertensive heart disease, infiltrative cardiomyopathy, apical hypertrophic cardiomyopathy and endomyocardial eosinophilic disease. Early diagnosis is important because of the high risk of HF, fatal ventricular arrhythmias and embolism.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">6</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Prognosis is poor and the treatment for end-stage HF is cardiac transplantation. Life-threatening ventricular arrhythmias are an indication for an implantable cardioverter-defibrillator. The main mechanisms of death in LVNC are sudden death and refractory HF.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">16</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The patient presented here, although asymptomatic, was classified as having stage B HF according to the American College of Cardiology/American Heart Association guidelines,<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">17</span></a> as he presented structural and functional alterations, including systolic dysfunction. Such patients are at high risk of developing symptomatic HF and so prompt treatment is indicated.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">17</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The pulmonary embolism diagnosed in our patient appears to have been due to immobilization of the left leg and unrelated to LVNC, which increases risk for arterial thromboembolism and hence stroke.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">18</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Cardiologists are routinely called upon to assess patients’ preoperative risk. The aim is to identify undiagnosed conditions that could increase risk for perioperative morbidity and mortality and to suggest ways to reduce the risk.<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">19,20</span></a> Assessment is always multifactorial and risk factors for postoperative cardiac events include the type of procedure and factors specific to the patient.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">21</span></a> Routine ECG assessment is not recommended for patients at low cardiac risk about to undergo low-risk surgery, since it could delay the operation unnecessarily, increase costs and increase patient anxiety.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">12</span></a> Some guidelines do suggest a preoperative ECG, but such recommendations are generally based on low-level evidence and the opinion of specialists.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">22</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The SBC recommends preoperative ECG in selected cases, but considers routine ECG a class III recommendation, level of evidence C, for asymptomatic individuals undergoing low-risk surgery.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">13</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">In the case presented, the ECG requested by the surgeon showed complete LBBB, and since LBBB has prognostic significance even in asymptomatic individuals, or those without known heart disease,<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">23</span></a> it was decided to perform TDI, which led to a diagnosis of LVNC.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0085" class="elsevierStylePara elsevierViewall">The ECG is a low-cost and accessible tool for identifying myocardial disease and arrhythmias. A routine ECG in preoperative assessment may help identify conditions that, although asymptomatic, could increase perioperative risk. In the case presented the early diagnosis of LVNC, a condition that can lead to HF, thromboembolic events, ventricular tachyarrhythmias and death, enabled the patient to receive a better quality of care. The recommendation in the SBC guidelines not to perform ECG routinely in preoperative assessment is based on the opinion of specialists, and the question should be settled definitively by means of methodologically robust studies.</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="par0090" 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="par0095" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Right to privacy and informed consent</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Funding</span><p id="par0105" class="elsevierStylePara elsevierViewall">There was no external funding for this article.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Academic links</span><p id="par0110" class="elsevierStylePara elsevierViewall">This article is part of the heart failure research component of the Post-Graduate Course in Cardiovascular Science at Universidade Federal Fluminense.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">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:13 [ 0 => array:3 [ "identificador" => "xres827483" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec823747" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres827484" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec823748" "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" => "Funding" ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Academic links" ] 11 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflicts of interest" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-04-20" "fechaAceptado" => "2015-09-13" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec823747" "palabras" => array:3 [ 0 => "Isolated left ventricular non-compaction" 1 => "Preoperative care" 2 => "Pulmonary embolism" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec823748" "palabras" => array:3 [ 0 => "Miocárdio ventricular isolado não compactado" 1 => "Cuidados pré-operatórios" 2 => "Embolia pulmonar" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Isolated left ventricular non-compaction is a rare disease classified as a primary genetic cardiomyopathy and is characterized by heart failure, systemic embolism and ventricular arrhythmias. The diagnosis is established by Doppler echocardiography. We report the case of an asymptomatic young adult, with no history of heart disease, who underwent preoperative assessment for low-risk orthopedic surgery. The electrocardiogram showed left bundle branch block, which prompted further investigation with Doppler echocardiography, cardiac computed tomography angiography and cardiac magnetic resonance imaging. A diagnosis of isolated left ventricular non-compaction and pulmonary embolism was made. Some aspects of preoperative assessment in low-risk surgical patients are discussed.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A cardiomiopatia não compactada isolada do ventrículo é uma doença rara, classificada como uma cardiomiopatia genética primária. A doença é caracterizada por insuficiência cardíaca, embolia sistémica e arritmias ventriculares. O diagnóstico é estabelecido pelo ecodopplercardiograma. Relata-se o caso de adulto jovem assintomático, sem história prévia de cardiopatia, que realizou avaliação pré-operatória para cirurgia ortopédica de baixo risco. Eletrocardiograma apresentou bloqueio do ramo esquerdo, que suscitou investigação complementar com ecodopplercardiograma, angiotomografia do tórax e ressonância cardíaca. Concluiu-se pelo diagnóstico de cardiopatia não compactada isolada do ventrículo e embolia pulmonar. Discutem-se aspetos da avaliação pré-operatória em pacientes de baixo risco cirúrgico.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Antonio José AJ, do Couto AA, Mesquita ET, Ribeiro ML, de Souza Junior CV, de Andrade Martins W. Duas surpresas potencialmente fatais em avaliação pré-operatória de adulto jovem assintomático. Rev Port Cardiol. 2016;35:309.e1–309.e6.</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" => 677 "Ancho" => 996 "Tamanyo" => 87044 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Echocardiogram, apical 4-chamber view, showing global left ventricular systolic dysfunction located mainly in the mid anterolateral and apical walls. Non-compaction is also more prominent in the subendocardial myocardium than in the subepicardial region.</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" => 2281 "Ancho" => 1611 "Tamanyo" => 699377 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Computed tomography angiography showing signs of pulmonary embolism (arrows).</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" => 1220 "Ancho" => 1863 "Tamanyo" => 252217 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Cardiac magnetic resonance imaging showing left ventricular hypertrophy with increased trabeculation of the mid and apical walls.</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" => 960 "Ancho" => 1604 "Tamanyo" => 311279 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">24-hour Holter ECG monitoring showing an episode of paroxysmal supraventricular tachycardia.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:23 [ 0 => array:3 [ "identificador" => "bib0120" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Isolated noncompaction of left ventricular myocardium: a study of eight cases" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "T.K. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 8 | 8 | 16 |
| 2024 October | 46 | 30 | 76 |
| 2024 September | 54 | 26 | 80 |
| 2024 August | 61 | 31 | 92 |
| 2024 July | 37 | 35 | 72 |
| 2024 June | 31 | 29 | 60 |
| 2024 May | 53 | 28 | 81 |
| 2024 April | 36 | 31 | 67 |
| 2024 March | 50 | 21 | 71 |
| 2024 February | 42 | 14 | 56 |
| 2024 January | 30 | 25 | 55 |
| 2023 December | 28 | 26 | 54 |
| 2023 November | 32 | 23 | 55 |
| 2023 October | 22 | 17 | 39 |
| 2023 September | 23 | 23 | 46 |
| 2023 August | 29 | 18 | 47 |
| 2023 July | 14 | 17 | 31 |
| 2023 June | 15 | 7 | 22 |
| 2023 May | 36 | 11 | 47 |
| 2023 April | 29 | 11 | 40 |
| 2023 March | 47 | 18 | 65 |
| 2023 February | 48 | 20 | 68 |
| 2023 January | 37 | 13 | 50 |
| 2022 December | 44 | 24 | 68 |
| 2022 November | 53 | 27 | 80 |
| 2022 October | 39 | 16 | 55 |
| 2022 September | 40 | 48 | 88 |
| 2022 August | 42 | 41 | 83 |
| 2022 July | 32 | 36 | 68 |
| 2022 June | 32 | 30 | 62 |
| 2022 May | 36 | 41 | 77 |
| 2022 April | 37 | 27 | 64 |
| 2022 March | 23 | 36 | 59 |
| 2022 February | 29 | 34 | 63 |
| 2022 January | 30 | 38 | 68 |
| 2021 December | 18 | 28 | 46 |
| 2021 November | 30 | 38 | 68 |
| 2021 October | 38 | 41 | 79 |
| 2021 September | 19 | 34 | 53 |
| 2021 August | 34 | 30 | 64 |
| 2021 July | 18 | 31 | 49 |
| 2021 June | 25 | 18 | 43 |
| 2021 May | 22 | 43 | 65 |
| 2021 April | 74 | 57 | 131 |
| 2021 March | 62 | 15 | 77 |
| 2021 February | 67 | 26 | 93 |
| 2021 January | 61 | 20 | 81 |
| 2020 December | 42 | 15 | 57 |
| 2020 November | 45 | 20 | 65 |
| 2020 October | 36 | 14 | 50 |
| 2020 September | 72 | 15 | 87 |
| 2020 August | 40 | 10 | 50 |
| 2020 July | 61 | 9 | 70 |
| 2020 June | 36 | 14 | 50 |
| 2020 May | 38 | 10 | 48 |
| 2020 April | 53 | 12 | 65 |
| 2020 March | 61 | 9 | 70 |
| 2020 February | 149 | 30 | 179 |
| 2020 January | 62 | 9 | 71 |
| 2019 December | 73 | 9 | 82 |
| 2019 November | 53 | 11 | 64 |
| 2019 October | 42 | 7 | 49 |
| 2019 September | 93 | 16 | 109 |
| 2019 August | 44 | 7 | 51 |
| 2019 July | 62 | 10 | 72 |
| 2019 June | 59 | 19 | 78 |
| 2019 May | 43 | 6 | 49 |
| 2019 April | 44 | 16 | 60 |
| 2019 March | 101 | 16 | 117 |
| 2019 February | 71 | 15 | 86 |
| 2019 January | 77 | 10 | 87 |
| 2018 December | 46 | 16 | 62 |
| 2018 November | 140 | 10 | 150 |
| 2018 October | 361 | 19 | 380 |
| 2018 September | 95 | 14 | 109 |
| 2018 August | 194 | 10 | 204 |
| 2018 July | 36 | 9 | 45 |
| 2018 June | 33 | 3 | 36 |
| 2018 May | 63 | 5 | 68 |
| 2018 April | 64 | 9 | 73 |
| 2018 March | 85 | 10 | 95 |
| 2018 February | 67 | 7 | 74 |
| 2018 January | 98 | 7 | 105 |
| 2017 December | 156 | 15 | 171 |
| 2017 November | 67 | 10 | 77 |
| 2017 October | 24 | 7 | 31 |
| 2017 September | 31 | 5 | 36 |
| 2017 August | 38 | 10 | 48 |
| 2017 July | 21 | 10 | 31 |
| 2017 June | 35 | 5 | 40 |
| 2017 May | 36 | 5 | 41 |
| 2017 April | 24 | 8 | 32 |
| 2017 March | 40 | 4 | 44 |
| 2017 February | 44 | 5 | 49 |
| 2017 January | 49 | 7 | 56 |
| 2016 December | 48 | 6 | 54 |
| 2016 November | 21 | 2 | 23 |
| 2016 October | 25 | 3 | 28 |
| 2016 September | 25 | 9 | 34 |
| 2016 August | 6 | 1 | 7 |
| 2016 July | 26 | 9 | 35 |
| 2016 June | 20 | 21 | 41 |
| 2016 May | 8 | 40 | 48 |
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