Case report
Mitral valve aneurysm: A serious complication of aortic valve endocarditis
Aneurisma da válvula mitral: uma complicação grave da endocardite valvular aórtica
Maria João Sousa
, Vasco Alves, Sofia Cabral, Nuno Antunes, Luís Sousa Pereira, Filomena Oliveira, João Silveira, Severo Torres
Corresponding author
Serviço de Cardiologia, Centro Hospitalar do Porto, Porto, Portugal
Read
7819
Timeswas read the article
1967
Total PDF
5852
Total HTML
Share statistics
array:25 [ "pii" => "S2174204916302057" "issn" => "21742049" "doi" => "10.1016/j.repce.2016.10.007" "estado" => "S300" "fechaPublicacion" => "2016-11-01" "aid" => "876" "copyright" => "Sociedade Portuguesa de Cardiologia" "copyrightAnyo" => "2016" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Rev Port Cardiol. 2016;35:621.e1-5" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 3319 "formatos" => array:3 [ "EPUB" => 202 "HTML" => 2565 "PDF" => 552 ] ] "Traduccion" => array:1 [ "en" => array:20 [ "pii" => "S0870255116301871" "issn" => "08702551" "doi" => "10.1016/j.repc.2016.02.006" "estado" => "S300" "fechaPublicacion" => "2016-11-01" "aid" => "876" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Rev Port Cardiol. 2016;35:621.e1-5" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 4667 "formatos" => array:3 [ "EPUB" => 221 "HTML" => 3834 "PDF" => 612 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Mitral valve aneurysm: A serious complication of aortic valve endocarditis" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "621.e1" "paginaFinal" => "621.e5" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Aneurisma da válvula mitral: uma complicação grave da endocardite valvular aórtica" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "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" => 885 "Ancho" => 2501 "Tamanyo" => 207899 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Transthoracic echocardiogram (parasternal long-axis view). (A) Saccular bulge on the atrial side of the anterior mitral valve leaflet (small arrow) and a vegetation on the aortic valve prolapsing into the left ventricular outflow tract, in close contact with the anterior mitral valve leaflet (long arrow); (B) significant mitral regurgitation (color flow Doppler).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Maria João Sousa, Vasco Alves, Sofia Cabral, Nuno Antunes, Luís Sousa Pereira, Filomena Oliveira, João Silveira, Severo Torres" "autores" => array:8 [ 0 => array:2 [ "nombre" => "Maria João" "apellidos" => "Sousa" ] 1 => array:2 [ "nombre" => "Vasco" "apellidos" => "Alves" ] 2 => array:2 [ "nombre" => "Sofia" "apellidos" => "Cabral" ] 3 => array:2 [ "nombre" => "Nuno" "apellidos" => "Antunes" ] 4 => array:2 [ "nombre" => "Luís Sousa" "apellidos" => "Pereira" ] 5 => array:2 [ "nombre" => "Filomena" "apellidos" => "Oliveira" ] 6 => array:2 [ "nombre" => "João" "apellidos" => "Silveira" ] 7 => array:2 [ "nombre" => "Severo" "apellidos" => "Torres" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2174204916302057" "doi" => "10.1016/j.repce.2016.10.007" "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/S2174204916302057?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255116301871?idApp=UINPBA00004E" "url" => "/08702551/0000003500000011/v1_201610280519/S0870255116301871/v1_201610280519/en/main.assets" ] ] "itemSiguiente" => array:20 [ "pii" => "S2174204916302112" "issn" => "21742049" "doi" => "10.1016/j.repce.2016.10.013" "estado" => "S300" "fechaPublicacion" => "2016-11-01" "aid" => "880" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "sco" "cita" => "Rev Port Cardiol. 2016;35:623-5" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2108 "formatos" => array:3 [ "EPUB" => 182 "HTML" => 1538 "PDF" => 388 ] ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Image in Cardiology</span>" "titulo" => "Bioresorbable scaffold adjustment in an ostial lesion with the Szabo technique" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "623" "paginaFinal" => "625" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Ajuste de plataforma biorreabsorvível em lesão ostial pela técnica de Szabo" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "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" => 1320 "Ancho" => 1501 "Tamanyo" => 312662 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Coronary angiography showing severe disease of the mid left anterior descending (LAD) artery, involving the bifurcation with the first major septal branch (Medina 1,1,1) (A and B); after angioplasty of the first septal branch with a drug-eluting balloon and LAD predilation (C), a bioresorbable scaffold was implanted in the mid LAD using the Szabo technique (D and E).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Carlos Galvão Braga, Raymundo Ocaranza-Sánchez, Santiago Gestal, Ramiro Trillo, José Ramón González-Juanatey" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Carlos" "apellidos" => "Galvão Braga" ] 1 => array:2 [ "nombre" => "Raymundo" "apellidos" => "Ocaranza-Sánchez" ] 2 => array:2 [ "nombre" => "Santiago" "apellidos" => "Gestal" ] 3 => array:2 [ "nombre" => "Ramiro" "apellidos" => "Trillo" ] 4 => array:2 [ "nombre" => "José Ramón" "apellidos" => "González-Juanatey" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0870255116301913" "doi" => "10.1016/j.repc.2015.12.012" "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/S0870255116301913?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204916302112?idApp=UINPBA00004E" "url" => "/21742049/0000003500000011/v1_201611160155/S2174204916302112/v1_201611160155/en/main.assets" ] "itemAnterior" => array:20 [ "pii" => "S2174204916301532" "issn" => "21742049" "doi" => "10.1016/j.repce.2016.03.010" "estado" => "S300" "fechaPublicacion" => "2016-11-01" "aid" => "857" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Rev Port Cardiol. 2016;35:619.e1-5" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 4238 "formatos" => array:3 [ "EPUB" => 238 "HTML" => 3380 "PDF" => 620 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Hypersensitivity to aspirin and urgent percutaneous coronary intervention: A therapeutic challenge" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "619.e1" "paginaFinal" => "619.e5" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Hipersensibilidade à aspirina e coronariografia urgente: desafio terapêutico" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "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" => 2028 "Ancho" => 2340 "Tamanyo" => 231716 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Decision algorithm for patients with coronary artery disease and NSAID sensitivity. CAD: coronary artery disease. Adapted from Gollapudi et al.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a></p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Tatiana Duarte, Sara Gonçalves, Catarina Sá, Rita Marinheiro, Rita Rodrigues, Filipe Seixo, Elza Tomas, Rui Caria" "autores" => array:8 [ 0 => array:2 [ "nombre" => "Tatiana" "apellidos" => "Duarte" ] 1 => array:2 [ "nombre" => "Sara" "apellidos" => "Gonçalves" ] 2 => array:2 [ "nombre" => "Catarina" "apellidos" => "Sá" ] 3 => array:2 [ "nombre" => "Rita" "apellidos" => "Marinheiro" ] 4 => array:2 [ "nombre" => "Rita" "apellidos" => "Rodrigues" ] 5 => array:2 [ "nombre" => "Filipe" "apellidos" => "Seixo" ] 6 => array:2 [ "nombre" => "Elza" "apellidos" => "Tomas" ] 7 => array:2 [ "nombre" => "Rui" "apellidos" => "Caria" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "pt" => array:9 [ "pii" => "S0870255116301482" "doi" => "10.1016/j.repc.2016.03.008" "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/S0870255116301482?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204916301532?idApp=UINPBA00004E" "url" => "/21742049/0000003500000011/v1_201611160155/S2174204916301532/v1_201611160155/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Mitral valve aneurysm: A serious complication of aortic valve endocarditis" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "621.e1" "paginaFinal" => "621.e5" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Maria João Sousa, Vasco Alves, Sofia Cabral, Nuno Antunes, Luís Sousa Pereira, Filomena Oliveira, João Silveira, Severo Torres" "autores" => array:8 [ 0 => array:4 [ "nombre" => "Maria João" "apellidos" => "Sousa" "email" => array:1 [ 0 => "maria.sousa.101@sapo.pt" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Vasco" "apellidos" => "Alves" ] 2 => array:2 [ "nombre" => "Sofia" "apellidos" => "Cabral" ] 3 => array:2 [ "nombre" => "Nuno" "apellidos" => "Antunes" ] 4 => array:2 [ "nombre" => "Luís Sousa" "apellidos" => "Pereira" ] 5 => array:2 [ "nombre" => "Filomena" "apellidos" => "Oliveira" ] 6 => array:2 [ "nombre" => "João" "apellidos" => "Silveira" ] 7 => array:2 [ "nombre" => "Severo" "apellidos" => "Torres" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Serviço de Cardiologia, Centro Hospitalar do Porto, Porto, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Aneurisma da válvula mitral: uma complicação grave da endocardite valvular aórtica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 576 "Ancho" => 1614 "Tamanyo" => 136921 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiogram (3-chamber view). (A) Ruptured aneurysm of the anterior mitral valve leaflet. The long arrow points to the entry site and the small arrow points to the exit site of the aneurysm; (B) color Doppler image showing two mitral regurgitation jets: a small jet through the leaflet coaptation point (small arrow) and a much more significant one through the aneurysm (long arrow).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Case report</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 70-year-old male patient with type 2 diabetes mellitus and chronic hepatitis C virus infection presented to the emergency department with a four-month history of intermittent fever, night sweats, weight loss and progressive dyspnea. There was no past history of cardiovascular disease or illicit drug abuse. On physical examination, he was febrile (38.1<span class="elsevierStyleHsp" style=""></span>°C), his pulse was 124 bpm, blood pressure was 114/73 mmHg and he had signs of left heart failure. Cardiac auscultation disclosed a grade 3/6 pansystolic murmur at the apex. Blood cultures were positive for <span class="elsevierStyleItalic">Streptococcus viridans</span>.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Transthoracic echocardiography (TTE) showed multiple aortic valve vegetations (some prolapsing into the left ventricular outflow tract), mild aortic regurgitation and a large saccular bulge originating from the anterior mitral valve leaflet and protruding into the left atrium with severe mitral regurgitation (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>); left ventricular systolic function was normal. With transesophageal echocardiography (TEE) it became clear that the saccular bulging on the mitral valve was an anterior mitral valve leaflet aneurysm with two rupture sites (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>). Color flow Doppler showed two regurgitant jets: one through the coaptation margin of the mitral valve leaflets and the other across the perforated aneurysm (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>). There was no evidence of either aortic ring abscess formation or extension along the mitral-aortic intervalvular fibrosa.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Antibiotic therapy was started with vancomycin plus gentamicin (due to penicillin allergy) for infective endocarditis (IE). After clinical stabilization, he was referred for urgent cardiac surgery. Given his clinical stability, surgery was delayed for four more days of antibiotic therapy. The patient died suddenly one day before scheduled surgical intervention.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">Mitral valve aneurysms (MVAs) are uncommon but potentially serious complications, occurring most frequently in association with aortic valve endocarditis.<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">1–4</span></a> The first case was reported by Morand in 1729.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">5</span></a> In 1970, Gonzalez-Lavin et al.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">6</span></a> reported secondary involvement of the mitral valve with leaflet aneurysm in two (3.4%) patients out of 58 who underwent aortic valve surgery for IE. Similar results were reported in 1992 by Karalis et al.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">7</span></a> in a group of 55 patients with aortic valve endocarditis evaluated by TEE. More recent reports present a very low incidence, around 0.2-0.29% of patients who undergo TEE.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">2,4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Although most frequently associated with IE, other non-infectious etiologies have been reported including congenital cardiac structural defects, extreme forms of mitral valve prolapse, Libman-Sacks endocarditis and connective tissue disorders such as Marfan syndrome, Ehlers-Danlos syndrome, pseudoxanthoma elasticum and osteogenesis imperfecta.<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">4,9–13</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Because MVA is rare in the absence of IE, an infectious etiology will be at least partly responsible for leaflet degeneration. Proposed mechanisms for the development of MVA in the setting of aortic valve endocarditis include direct extension of the infection through the mitral-aortic intervalvular fibrosa to the anterior mitral valve leaflet with abscess formation and subsequent drainage, seeding of the anterior mitral valve leaflet by the aortic regurgitant jet (‘jet lesion’),<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">1,3,8,14–16</span></a> or through direct contact with an aortic vegetation prolapsing into the left ventricular outflow tract (‘kissing vegetation’), especially if the vegetation exceeds 6 mm in size.<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">17</span></a> These processes are thought to cause localized inflammation, weakness, dissection, and subsequent expansion of the valvular tissue, which in turn protrudes toward the left atrium due to ventricular systolic pressure, leading to aneurysm formation.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">2,18–21</span></a> In our case, because aortic regurgitation was only mild, we believe that the most likely mechanism for aneurysm development was previous abscess formation (secondary to direct extension of infection from the aortic valve or a prolapsing aortic vegetation) followed by rupture and drainage.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The diagnosis may be suspected by TTE but TEE is more sensitive for detecting MVA, leaflet rupture and mitral regurgitation.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">2,4,22–25</span></a> Recently, a few reports have highlighted the role of real-time three-dimensional echocardiography to better define the anatomical features of MVA preoperatively.<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">16,26–28</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Echocardiography shows MVA as a localized saccular bulge of the mitral valve leaflet toward the left atrium communicating with the left ventricle, expanding in systole and collapsing in diastole.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">2</span></a> Diastolic expansion can occur in cases of MVA rupture or severe aortic regurgitation.<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">28</span></a> These lesions can vary from a few mm to 4 cm in diameter and may contain thrombi.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">8</span></a> The anterior leaflet is much more commonly involved than the posterior leaflet.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">2–4</span></a> The diagnosis of perforation is based on the presence of a high-velocity regurgitant jet traversing the aneurysm in systole and further supported by demonstration of an interrupted segment of the aneurysm by two-dimensional examination.<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">4,29</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">MVA must be differentiated from various abnormalities with similar echocardiographic appearance including severe mitral valve prolapse, diverticulum of the mitral valve, large valvular vegetation, flail valve leaflet, blood cyst of the papillary muscle, cystic atrial myxoma or non-endothelialized cyst of the mitral valve.<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">24,30</span></a> Color flow Doppler helps distinguish an aneurysm from other similar-looking abnormalities by demonstrating direct communication between the aneurysm and the left ventricle.<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">22</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Potential complications of these aneurysms include rupture, thromboembolism and recurrent infection. MVAs can also cause severe mitral regurgitation due to perforation of the aneurysm or as a result of leaflet coaptation defect caused by the mass effect of the aneurysm, and may precipitate rapid deterioration of hemodynamic status.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The optimal management strategy for MVAs has not yet been well defined. A few reports have shown that conservative management of uncomplicated MVAs, with close follow-up, is possible.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">2,31</span></a> In cases of MVA rupture or severe mitral regurgitation or if the patient needs aortic valve replacement surgery, then mitral valve surgery should be considered.<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">4,15,31</span></a> Conservative mitral valve surgery for aneurysm correction is not always possible; it depends on the degree of valve destruction and the anatomic disorder.<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">32</span></a> When it is unsuitable for repair,<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">32–34</span></a> mitral valve replacement may be the only viable option.<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">25,35,36</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In conclusion, MVAs are rare but potentially life-threatening complications and should be carefully considered in the evaluation of every patient with aortic valve endocarditis. We report a case with impressive images of aortic valve endocarditis complicated by perforated mitral valve aneurysm and severe mitral regurgitation, diagnosed by TEE. This case highlights the importance of early diagnosis with appropriate imaging and timely surgical intervention to prevent fatal outcomes.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Ethical disclosures</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Protection of human and animal subjects</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Confidentiality of data</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Right to privacy and informed consent</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres757437" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec759517" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres757436" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec759518" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Right to privacy and informed consent" ] ] ] 7 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of interest" ] 8 => array:2 [ "identificador" => "xack251951" "titulo" => "Acknowledgments" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-11-18" "fechaAceptado" => "2016-02-06" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec759517" "palabras" => array:5 [ 0 => "Mitral valve" 1 => "Aneurysm" 2 => "Aortic valve" 3 => "Endocarditis" 4 => "Echocardiography" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec759518" "palabras" => array:5 [ 0 => "Válvula mitral" 1 => "Aneurisma" 2 => "Válvula aórtica" 3 => "Endocardite" 4 => "Ecocardiografia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Mitral valve aneurysms are rare and occur most commonly in association with aortic valve endocarditis. Transesophageal echocardiography is the most sensitive imaging modality for the diagnosis of this entity and its potential complications, such as leaflet rupture and mitral regurgitation, which mandate prompt surgical intervention.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We present the case of a 70-year-old male patient with aortic valve endocarditis complicated with a ruptured aneurysm of the anterior mitral valve leaflet and associated severe mitral regurgitation, diagnosed by transesophageal echocardiography, with impressive images. We hypothesized that the aneurysm developed through direct extension of infection from the aortic valve or from a prolapsing aortic vegetation, with abscess formation and subsequent rupture and drainage. This case highlights the importance of appropriate imaging for early detection and timely surgical intervention (repair or replacement) to prevent fatal outcomes.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Os aneurismas da válvula mitral são raros e, habitualmente, encontram-se associados a endocardite da válvula aórtica. O ecocardiograma transesofágico é a modalidade imagiológica mais sensível para o diagnóstico desta entidade e das suas potenciais complicações, tais como perfuração e regurgitação mitral, que exigem intervenção cirúrgica urgente.</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Apresentamos o caso clínico de um doente de 70 anos, do sexo masculino, com endocardite da válvula aórtica complicada por aneurisma perfurado do folheto anterior da válvula mitral e regurgitação mitral grave associada, diagnosticada por ecocardiograma transesofágico com imagens muito ilustrativas. Admitimos como hipótese, mais provável, que o aneurisma se desenvolveu por extensão direta da infeção a partir da válvula aórtica ou do prolapso de uma vegetação aórtica, com formação de abcesso e subsequente rotura e drenagem. Este caso realça a importância das modalidades imagiológicas adequadas no diagnóstico precoce do aneurisma da válvula mitral e da intervenção cirúrgica atempada (plastia ou substituição) na prevenção de eventos fatais.</p></span>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 572 "Ancho" => 1615 "Tamanyo" => 121286 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Transthoracic echocardiogram (parasternal long-axis view). (A) Saccular bulge on the atrial side of the anterior mitral valve leaflet (small arrow) and a vegetation on the aortic valve prolapsing into the left ventricular outflow tract, in close contact with the anterior mitral valve leaflet (long arrow); (B) significant mitral regurgitation (color flow Doppler).</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" => 573 "Ancho" => 1614 "Tamanyo" => 110027 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiogram. (A) 2-chamber view: saccular bulge (aneurysm) on the atrial side of the anterior mitral valve leaflet (arrow); (B) 5-chamber view: bilobular image (aneurysm) on the atrial side of the anterior mitral valve leaflet (arrow).</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" => 576 "Ancho" => 1614 "Tamanyo" => 136921 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiogram (3-chamber view). (A) Ruptured aneurysm of the anterior mitral valve leaflet. The long arrow points to the entry site and the small arrow points to the exit site of the aneurysm; (B) color Doppler image showing two mitral regurgitation jets: a small jet through the leaflet coaptation point (small arrow) and a much more significant one through the aneurysm (long arrow).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:36 [ 0 => array:3 [ "identificador" => "bib0185" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mitral valve aneurysm: clinical features, echocardiographic-pathologic correlations" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "C. Reid" 1 => "A. Chandraratna" 2 => "E. Harrison" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "1983" "volumen" => "2" "paginaInicial" => "460" "paginaFinal" => "464" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/6875109" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0190" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical, anatomic, and echocardiographic characteristics of aneurysms of the mitral valve" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "I. Vilacosta" 1 => "J. Román" 2 => "C. Sarriá" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Cardiol" "fecha" => "1999" "volumen" => "84" "paginaInicial" => "110" "paginaFinal" => "113" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10404866" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0195" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mitral valve aneurysm associated with aortic valve endocarditis and regurgitation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. Raval" 1 => "A. Menkis" 2 => "D. Boughner" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Heart Surg Forum" "fecha" => "2002" "volumen" => "5" "paginaInicial" => "298" "paginaFinal" => "299" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12538147" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S1470204512702942" "estado" => "S300" "issn" => "14702045" ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0200" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical and echocardiographic evaluation of mitral valve aneurysms: a retrospective, single center study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A. Guler" 1 => "C. Karabay" 2 => "O. Gursoy" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s10554-014-0365-4" "Revista" => array:6 [ "tituloSerie" => "Int J Cardiovasc Imaging" "fecha" => "2014" "volumen" => "30" "paginaInicial" => "535" "paginaFinal" => "541" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24420419" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0205" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Aneurysm of heart valves" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "S. Jarcho" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Cardiol" "fecha" => "1968" "volumen" => "22" "paginaInicial" => "273" "paginaFinal" => "276" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/4874961" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0210" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The importance of the jet lesion in bacterial endocarditis involving the left heart. Surgical considerations" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "L. Gonzalez-Lavin" 1 => "M. Lise" 2 => "D. Ross" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Thorac Cardiovasc Surg" "fecha" => "1970" "volumen" => "59" "paginaInicial" => "185" "paginaFinal" => "192" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/5445473" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0215" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Transesophageal echocardiographic recognition of subaortic complications in aortic valve endocarditis. Clinical and surgical implications" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "D. Karalis" 1 => "R. Bansal" 2 => "A. Hauck" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Circulation" "fecha" => "1992" "volumen" => "86" "paginaInicial" => "353" "paginaFinal" => "362" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1638704" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0090429508017810" "estado" => "S300" "issn" => "00904295" ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0220" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Aneurysm of the mitral valve in subacute bacterial endocarditis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "N. Maclean" 1 => "M. Macdonal" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Br Heart J" "fecha" => "1957" "volumen" => "19" "paginaInicial" => "550" "paginaFinal" => "554" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/13471822" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0225" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Congenital obstructive mitral valve aneurysm" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "K. Kathir" 1 => "R.F. Dunn" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Int Med J" "fecha" => "2003" "volumen" => "33" "paginaInicial" => "541" "paginaFinal" => "542" ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0230" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mitral valve aneurysm revealed by cross-sectional echocardiography in a patient with mitral valve prolapse" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A. Ruckel" 1 => "A. Erbel" 2 => "B. Henkel" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Int J Cardiol" "fecha" => "1984" "volumen" => "6" "paginaInicial" => "633" "paginaFinal" => "637" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/6500753" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0235" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Perforated mitral valve aneurysm associated with Libman-Sacks endocarditis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "T. Takayama" 1 => "M. Teramura" 2 => "H. Sakai" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Int Med" "fecha" => "2008" "volumen" => "47" "paginaInicial" => "1605" "paginaFinal" => "1608" ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0240" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ruptured aneurysm of the mitral valve in a Marfan-like syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "G. Edynak" 1 => "A. Rawson" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Am J Cardiol" "fecha" => "1963" "volumen" => "11" "paginaInicial" => "674" "paginaFinal" => "677" ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0245" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pseudoxanthoma elasticum and mitral-valve prolapse" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M.G. Lebwohl" 1 => "D. Distefano" 2 => "P.G. Prioleau" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJM198207223070406" "Revista" => array:7 [ "tituloSerie" => "N Engl J Med" "fecha" => "1982" "volumen" => "307" "paginaInicial" => "228" "paginaFinal" => "231" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7088072" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S1470204513706119" "estado" => "S300" "issn" => "14702045" ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0250" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mitral valve aneurysm due to severe aortic valve regurgitation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "T. Cai" 1 => "J. Moody" 2 => "E. Sako" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Circulation" "fecha" => "1999" "volumen" => "100" "paginaInicial" => "e53" "paginaFinal" => "e56" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10491384" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0255" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mitral valve aneurysm with infective endocarditis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C. Gao" 1 => "C. Xiao" 2 => "B. Li" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S0003-4975(03)01602-3" "Revista" => array:6 [ "tituloSerie" => "Ann Thorac Surg" "fecha" => "2004" "volumen" => "78" "paginaInicial" => "2171" "paginaFinal" => "2173" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15561066" "web" => "Medline" ] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0260" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anterior mitral valve aneurysm perforation in a patient with pre-existing aortic regurgitation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "R. Citro" 1 => "A. Silverio" 2 => "R. Ascoli" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4081/monaldi.2012.114" "Revista" => array:6 [ "tituloSerie" => "Monaldi Arch Chest Dis" "fecha" => "2012" "volumen" => "78" "paginaInicial" => "210" "paginaFinal" => "211" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23659107" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0265" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The importance of secondary mitral valve involvement in primary aortic valve endocarditis. The mitral kissing vegetation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "C. Piper" 1 => "R. Hetzer" 2 => "R. Korfer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1053/euhj.2001.2689" "Revista" => array:6 [ "tituloSerie" => "Eur Heart J" "fecha" => "2002" "volumen" => "23" "paginaInicial" => "79" "paginaFinal" => "86" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11741365" "web" => "Medline" ] ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0270" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anterior mitral valve aneurysm perforation secondary to aortic valve endocarditis detected by Doppler colour flow mapping" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "P. Decroly" 1 => "J. Vandenbossche" 2 => "M. Englert" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Eur Heart J" "fecha" => "1989" "volumen" => "10" "paginaInicial" => "186" "paginaFinal" => "189" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2924788" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0959804911001912" "estado" => "S300" "issn" => "09598049" ] ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0275" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The importance of the echocardiographic diagnosis of a mycotic aneurysm of the mitral septal leaflet in infective endocarditis of the aortic valve: the surgical implication" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "C. Delqado" 1 => "R. Martín" 2 => "J. Vázquez" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Rev Esp Cardiol" "fecha" => "1991" "volumen" => "44" "paginaInicial" => "672" "paginaFinal" => "676" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1801096" "web" => "Medline" ] ] ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0280" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Review: mitral valve aneurysms in infective endocarditis: mechanisms, clinical recognition, and treatment" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J.J. Silbiger" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Heart Valve Dis" "fecha" => "2009" "volumen" => "18" "paginaInicial" => "476" "paginaFinal" => "480" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20099686" "web" => "Medline" ] ] ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0285" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "An unusual cause of severe mitral regurgitation in a patient with aortic valve endocarditis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M. Eisemen" 1 => "A. Schroeder" 2 => "S. Piotr" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1053/j.jvca.2013.10.021" "Revista" => array:6 [ "tituloSerie" => "J Cardiothorac Vasc Anesth" "fecha" => "2014" "volumen" => "28" "paginaInicial" => "1432" "paginaFinal" => "1434" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24461358" "web" => "Medline" ] ] ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0290" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The role of color flow Doppler in the echocardiographic diagnosis of mitral valve aneurysm" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M. Changlani" 1 => "D. Lieb" 2 => "D. Kaczkowski" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Am Soc Echocardiogr" "fecha" => "1993" "volumen" => "6" "paginaInicial" => "610" "paginaFinal" => "612" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8311968" "web" => "Medline" ] ] ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib0295" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Transesophageal versus transthoracic echocardiography for diagnosing mitral valve perforation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "D.G. Cziner" 1 => "B.P. Rosenzweig" 2 => "E.S. Katz" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Am J Cardiol" "fecha" => "1992" "volumen" => "69" "paginaInicial" => "1495" "paginaFinal" => "1497" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1590245" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0022534715041051" "estado" => "S300" "issn" => "00225347" ] ] ] ] ] ] ] 23 => array:3 [ "identificador" => "bib0300" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mitral and tricuspid valve aneurysm evaluated by transesophageal echocardiography" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M. Mollod" 1 => "K. Felner" 2 => "J. Felner" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Cardiol" "fecha" => "1997" "volumen" => "79" "paginaInicial" => "1269" "paginaFinal" => "1272" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9164903" "web" => "Medline" ] ] ] ] ] ] ] ] 24 => array:3 [ "identificador" => "bib0305" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Aneurysm of the anterior leaflet of the mitral valve secondary to aortic valve endocarditis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "P. Marcos-Alberca" 1 => "J. Serrano" 2 => "I. Fernández-Rozas" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Am Soc Echocardiogr" "fecha" => "2000" "volumen" => "13" "paginaInicial" => "1050" "paginaFinal" => "1052" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11093109" "web" => "Medline" ] ] ] ] ] ] ] ] 25 => array:3 [ "identificador" => "bib0310" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "E72-6.8" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ruptured anterior mitral leaflet aneurysm in aortic valve infective endocarditis – evaluation by three-dimensional echocardiography" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "R. Kharwar" 1 => "A. Mohanty" 2 => "A. Sharma" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "Echocardiography" "fecha" => "2014" "volumen" => "31" ] ] ] ] ] ] 26 => array:3 [ "identificador" => "bib0315" "etiqueta" => "27" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Incremental value of three-dimensional transthoracic echocardiography in the assessment of ruptured aneurysm of anterior mitral leaflet" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "S. Vijay" 1 => "B. Tiwari" 2 => "M. Misra" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Ecocardiography" "fecha" => "2014" "volumen" => "31" "paginaInicial" => "E24" "paginaFinal" => "E26" "itemHostRev" => array:3 [ "pii" => "S0302283814006241" "estado" => "S300" "issn" => "03022838" ] ] ] ] ] ] ] 27 => array:3 [ "identificador" => "bib0320" "etiqueta" => "28" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ruptured aneurysm of the anterior mitral leaflet in aortic valve infective endocarditis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "I. Zegri" 1 => "V. Monivas" 2 => "S. Mingo" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/echo.12831" "Revista" => array:6 [ "tituloSerie" => "Echocardiography" "fecha" => "2015" "volumen" => "32" "paginaInicial" => "720" "paginaFinal" => "722" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25365965" "web" => "Medline" ] ] ] ] ] ] ] ] 28 => array:3 [ "identificador" => "bib0325" "etiqueta" => "29" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Perforated aneurysm of the anterior mitral valve – a Doppler and two-dimensional echocardiographic report" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A. Chua" 1 => "C. Chiang" 2 => "Y. Lee" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "1990" "volumen" => "97" "paginaInicial" => "753" "paginaFinal" => "754" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2306980" "web" => "Medline" ] ] ] ] ] ] ] ] 29 => array:3 [ "identificador" => "bib0330" "etiqueta" => "30" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anterior mitral valve aneurysm: a subaortic complication of aortic valve endocarditis: a case report and review of literature" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M. Rachko" 1 => "A. Safi" 2 => "D. Yeshou" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Heart Dis" "fecha" => "2001" "volumen" => "3" "paginaInicial" => "145" "paginaFinal" => "147" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11975784" "web" => "Medline" ] ] ] ] ] ] ] ] 30 => array:3 [ "identificador" => "bib0335" "etiqueta" => "31" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Conservative management of mitral valve aneurysm" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "K. Gin" 1 => "J. Boone" 2 => "C. Thompson" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Am Soc Echocardiogr" "fecha" => "1993" "volumen" => "6" "paginaInicial" => "613" "paginaFinal" => "618" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8311969" "web" => "Medline" ] ] ] ] ] ] ] ] 31 => array:3 [ "identificador" => "bib0340" "etiqueta" => "32" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Conservative surgical treatment of mitral valve aneurysm secondary to aortic valve endocarditis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M. Vieira" 1 => "P. Pomerantzeff" 2 => "L. Pillco" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Echocardiography" "fecha" => "2003" "volumen" => "20" "paginaInicial" => "435" "paginaFinal" => "438" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12848863" "web" => "Medline" ] ] ] ] ] ] ] ] 32 => array:3 [ "identificador" => "bib0345" "etiqueta" => "33" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ruptured true aneurysm of mitral valve. A complication of aortic valve endocarditis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "T. English" 1 => "M. Honey" 2 => "W. Cleland" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Br Heart J" "fecha" => "1972" "volumen" => "34" "paginaInicial" => "434" "paginaFinal" => "436" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/4259848" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0302283812002229" "estado" => "S300" "issn" => "03022838" ] ] ] ] ] ] ] 33 => array:3 [ "identificador" => "bib0350" "etiqueta" => "34" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Bicuspid aortic valve endocarditis complicated by mitral valve aneurysm" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "N. Ruparelia" 1 => "D. Lawrence" 2 => "A. Elkington" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1540-8191.2011.01243.x" "Revista" => array:6 [ "tituloSerie" => "J Card Surg" "fecha" => "2011" "volumen" => "26" "paginaInicial" => "284" "paginaFinal" => "286" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21447085" "web" => "Medline" ] ] ] ] ] ] ] ] 34 => array:3 [ "identificador" => "bib0355" "etiqueta" => "35" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mitral valve aneurysm associated with aortic valve regurgitation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "O. Gulmez" 1 => "L. Sade" 2 => "A. Yildirir" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Arch Turk Soc Cardiol" "fecha" => "2009" "volumen" => "37" "paginaInicial" => "263" "paginaFinal" => "265" ] ] ] ] ] ] 35 => array:3 [ "identificador" => "bib0360" "etiqueta" => "36" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "Published online 15 April 2015. Available at <a class="elsevierStyleInterRef" id="intr0005" href="http://casereports.bmj.com/content/2015/bcr-2014-209092.abstract">http://casereports.bmj.com/content/2015/bcr-2014-209092.abstract</a> [accessed 31.10.15]" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Large mitral valve aneurysm with infective endocarditis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "S. Uematsu" 1 => "K. Ashima" 2 => "H. Tomioka" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:2 [ "tituloSerie" => "BMJ Case Rep" "fecha" => "2015" ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack251951" "titulo" => "Acknowledgments" "texto" => "<p id="par0075" class="elsevierStylePara elsevierViewall">The authors wish to thank the Cardiothoracic Surgery Department of Centro Hospitalar S. João, Porto, for rapidly accepting the patient transfer.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/21742049/0000003500000011/v1_201611160155/S2174204916302057/v1_201611160155/en/main.assets" "Apartado" => array:4 [ "identificador" => "9919" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case Reports" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21742049/0000003500000011/v1_201611160155/S2174204916302057/v1_201611160155/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204916302057?idApp=UINPBA00004E" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 8 | 6 | 14 |
| 2024 October | 41 | 33 | 74 |
| 2024 September | 37 | 29 | 66 |
| 2024 August | 39 | 29 | 68 |
| 2024 July | 44 | 35 | 79 |
| 2024 June | 46 | 24 | 70 |
| 2024 May | 51 | 18 | 69 |
| 2024 April | 40 | 23 | 63 |
| 2024 March | 56 | 24 | 80 |
| 2024 February | 40 | 26 | 66 |
| 2024 January | 45 | 26 | 71 |
| 2023 December | 33 | 25 | 58 |
| 2023 November | 37 | 33 | 70 |
| 2023 October | 41 | 23 | 64 |
| 2023 September | 34 | 22 | 56 |
| 2023 August | 36 | 16 | 52 |
| 2023 July | 34 | 6 | 40 |
| 2023 June | 43 | 13 | 56 |
| 2023 May | 73 | 26 | 99 |
| 2023 April | 44 | 10 | 54 |
| 2023 March | 55 | 23 | 78 |
| 2023 February | 46 | 22 | 68 |
| 2023 January | 41 | 15 | 56 |
| 2022 December | 48 | 28 | 76 |
| 2022 November | 85 | 23 | 108 |
| 2022 October | 59 | 24 | 83 |
| 2022 September | 53 | 35 | 88 |
| 2022 August | 56 | 25 | 81 |
| 2022 July | 61 | 38 | 99 |
| 2022 June | 60 | 35 | 95 |
| 2022 May | 41 | 35 | 76 |
| 2022 April | 60 | 26 | 86 |
| 2022 March | 62 | 34 | 96 |
| 2022 February | 74 | 27 | 101 |
| 2022 January | 80 | 21 | 101 |
| 2021 December | 39 | 34 | 73 |
| 2021 November | 66 | 37 | 103 |
| 2021 October | 133 | 42 | 175 |
| 2021 September | 65 | 24 | 89 |
| 2021 August | 77 | 40 | 117 |
| 2021 July | 56 | 28 | 84 |
| 2021 June | 45 | 27 | 72 |
| 2021 May | 56 | 30 | 86 |
| 2021 April | 121 | 73 | 194 |
| 2021 March | 75 | 25 | 100 |
| 2021 February | 115 | 28 | 143 |
| 2021 January | 54 | 13 | 67 |
| 2020 December | 70 | 13 | 83 |
| 2020 November | 75 | 19 | 94 |
| 2020 October | 58 | 11 | 69 |
| 2020 September | 74 | 18 | 92 |
| 2020 August | 46 | 11 | 57 |
| 2020 July | 80 | 19 | 99 |
| 2020 June | 69 | 14 | 83 |
| 2020 May | 69 | 5 | 74 |
| 2020 April | 61 | 21 | 82 |
| 2020 March | 65 | 24 | 89 |
| 2020 February | 170 | 16 | 186 |
| 2020 January | 66 | 10 | 76 |
| 2019 December | 70 | 7 | 77 |
| 2019 November | 41 | 14 | 55 |
| 2019 October | 49 | 4 | 53 |
| 2019 September | 46 | 4 | 50 |
| 2019 August | 35 | 11 | 46 |
| 2019 July | 39 | 9 | 48 |
| 2019 June | 46 | 13 | 59 |
| 2019 May | 38 | 10 | 48 |
| 2019 April | 41 | 18 | 59 |
| 2019 March | 26 | 14 | 40 |
| 2019 February | 53 | 6 | 59 |
| 2019 January | 91 | 8 | 99 |
| 2018 December | 77 | 13 | 90 |
| 2018 November | 86 | 13 | 99 |
| 2018 October | 204 | 18 | 222 |
| 2018 September | 67 | 17 | 84 |
| 2018 August | 30 | 11 | 41 |
| 2018 July | 20 | 3 | 23 |
| 2018 June | 27 | 9 | 36 |
| 2018 May | 33 | 10 | 43 |
| 2018 April | 61 | 20 | 81 |
| 2018 March | 63 | 3 | 66 |
| 2018 February | 37 | 4 | 41 |
| 2018 January | 157 | 7 | 164 |
| 2017 December | 140 | 17 | 157 |
| 2017 November | 69 | 24 | 93 |
| 2017 October | 48 | 12 | 60 |
| 2017 September | 38 | 10 | 48 |
| 2017 August | 44 | 8 | 52 |
| 2017 July | 46 | 24 | 70 |
| 2017 June | 48 | 22 | 70 |
| 2017 May | 54 | 40 | 94 |
| 2017 April | 35 | 25 | 60 |
| 2017 March | 85 | 28 | 113 |
| 2017 February | 141 | 19 | 160 |
| 2017 January | 61 | 14 | 75 |
| 2016 December | 67 | 26 | 93 |
| 2016 November | 31 | 12 | 43 |
Show all
