Case report
Coronary fistula to the right atrium: A challenge for the interventional cardiologist
Fístula coronária para a aurícula direita: um desafio para o cardiologista de intervenção
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Gonçalves, Cláudia C. Moura, Jorge A. Moreira, João A. Silva" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Edite" "apellidos" => "S. Gonçalves" "email" => array:1 [ 0 => "editesg@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Cláudia" "apellidos" => "C. Moura" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Jorge A." "apellidos" => "Moreira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "João" "apellidos" => "A. Silva" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Serviço de Cardiologia Pediátrica, Hospital de São João, Porto, Portugal" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Serviço de Cardiologia, Hospital de São João, Porto, Portugal" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Fístula coronária para a aurícula direita: um desafio para o cardiologista de intervenção" ] ] "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" => 848 "Ancho" => 900 "Tamanyo" => 55831 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">With the duct occluder device in place (arrowhead), a residual shunt is seen through the second orifice (arrow).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Coronary fistulas are rare congenital heart malformations that result in a connection between one or more of the coronary arteries and a cardiac chamber or great vessel, bypassing the myocardial capillary bed.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> In about half of cases the fistula originates from the right coronary artery, in one third from the left anterior descending artery and in about one-fifth from the circumflex artery.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The majority drain to the right side of the heart. Drainage, which can occur through one or multiple orifices, is more frequently into the right ventricle, followed by drainage into the right atrium.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Either of these possibilities will cause volume overload in right-sided structures and increased pulmonary vascular flow, similar to a left-to-right shunt from an atrial septal defect, ventricular septal defect or patent <span class="elsevierStyleItalic">ductus arteriosus</span>. Coronary fistulas are usually asymptomatic until the second decade of life. Occasionally a continuous murmur can be heard or cardiomegaly may be accidentally detected on a chest X-ray. Myocardial ischemia is also a possibility, usually in adult patients, due to coronary artery steal.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Other complications may include thrombosis, embolism, cardiac failure, atrial fibrillation, aneurysmal dilatation and rupture, endocarditis, endarteritis or arrhythmias.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,4</span></a> Although the electrocardiogram (ECG) and chest X-ray can be helpful and cardiac magnetic resonance imaging is of increasing importance, the main diagnostic technique remains cardiac catheterization and angiography, which provides information regarding the hemodynamic significance, location and size of the fistula.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Interventional catheterization techniques and surgery are both useful in closure of these vascular abnormalities.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A ten-year-old girl with no previous relevant medical history was referred for a pediatric cardiology assessment due to increased cardiothoracic ratio of 0.6. On physical examination she presented a grade 2/6 continuous murmur at the upper and middle sternal border and normal arterial pulses. The ECG was normal and the echocardiogram revealed a tubular structure (fistula) from the aorta to the right atrium. The right-sided chambers were slightly enlarged but ventricular contractility was normal.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient was referred for a diagnostic cardiac catheterization. Angiography confirmed a coronary fistula measuring 13 mm in diameter at the aortic end and draining into the right atrium (RA) through at least two small openings (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). The left anterior descending (LAD) and circumflex (Cx) arteries originated in the proximal extremity of the fistula through two separate orifices. Catheterization showed normal right and left heart pressures, oxygen saturation step-up in the right atrium and Qp:Qs of 1.7. Informed consent was obtained and percutaneous closure of the fistula was attempted using a 16 mm Amplatzer<span class="elsevierStyleSup">®</span> vascular plug II (AGA Medical). Through a femoral approach, a 7 Fr venous and a 6 Fr arterial sheath were used. A 6 Fr Concierge Amplatz Left 2 guiding catheter was positioned in the aorta at the fistula entrance and a 0.035 in Terumo<span class="elsevierStyleSup">®</span> hydrophilic guide wire was advanced along the fistula, until the right atrium was reached. The wire was then snared and an arteriovenous (AV) loop was created. A 7 Fr Amplatzer Delivery System was used to deploy the device through the atrial end (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>). A significant residual shunt was observed after deployment of the device. Cardiac enzymes were within normal range and the ECG showed no abnormalities. After this procedure anticoagulation was prescribed for six months and aspirin maintained thereafter.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Regular follow-up was performed and transthoracic echocardiography detected a residual shunt at the distal extremity of the fistula. One year after the first intervention, angiography was repeated and two small orifices were clearly seen in the extremity where the fistula drained into the right atrium. Percutaneous closure of these orifices was attempted. A 6 Fr venous sheath and a 6 Fr arterial sheath were used through a femoral approach. Two guide wires were advanced from the aortic end to the atrial end, one through each orifice, and two arteriovenous loops were created. Two 6 Fr Concierge Amplatz Left 2 guiding catheters were introduced in the distal extremity of the fistula. An 8/6 mm Amplatzer<span class="elsevierStyleSup">®</span> duct occluder (AGA Medical) was deployed through the atrial end to close the lower orifice (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>). The upper orifice was left open, due to dislocation and instability in the position of the guiding catheter in the distal part of the fistula, and the long duration of the procedure. Control angiography showed a residual shunt through the upper orifice.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Nine months after the second intervention, coronary angiography was repeated. No fistulous flow was detected, the fistula being occluded 2 cm before the emergence of the Cx artery (<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>). LAD and Cx artery flows were normal. Following the second procedure the patient remains asymptomatic and well. Antiplatelet therapy with aspirin was continued.</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">Complications related to coronary artery fistulas have been used as an argument to justify intervention, either surgical or percutaneous. Indications for closure include the presence of a large left-to-right shunt, left ventricular volume overload, left ventricular dysfunction, myocardial ischemia, congestive cardiac failure, and prevention of endocarditis.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,4</span></a> Several devices have been used for percutaneous closure of these vascular malformations, including the Amplatzer<span class="elsevierStyleSup">®</span> vascular plug,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Amplatzer<span class="elsevierStyleSup">®</span> duct occluder,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Amplatzer<span class="elsevierStyleSup">®</span> muscular VSD device and coils,<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5,7</span></a> but controversy remains as to the best approach. The choice of equipment, device and technique clearly depend on the morphology of the lesion, the experience of the attending cardiologist, and the patient's age and size. This case report highlights the difficulty the interventional cardiologist faces when approaching these malformations, since two devices had to be implanted before occlusion of the coronary fistula could be achieved. Although a small orifice was left open after the second percutaneous intervention due to technical difficulties in the placement of the catheter, a successful result was achieved. A possible explanation for this could be the sudden decrease of flow after occlusion of one of the orifices at the atrial extremity of the fistula.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Possible complications of closure of a coronary artery fistula include embolization of the device, myocardial ischemia and ECG abnormalities including T-wave changes and bundle branch block.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2,7</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:2 [ "identificador" => "xres250657" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec238223" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres250656" "titulo" => "Resumo" ] 3 => array:2 [ "identificador" => "xpalclavsec238224" "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" => "Conflicts of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-11-29" "fechaAceptado" => "2012-06-04" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec238223" "palabras" => array:4 [ 0 => "Cardiac catheterization" 1 => "Pediatric" 2 => "Intervention" 3 => "Device" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec238224" "palabras" => array:4 [ 0 => "Cateterismo cardíaco" 1 => "Pediátrico" 2 => "Intervenção" 3 => "Dispositivo" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Congenital coronary fistulas are rare conditions, frequently diagnosed as an incidental finding when a patient is referred for cardiac surgery for another reason. Treatment can be conservative, surgical or more recently through transcatheter closure, depending on local experience and the morphology of the fistula.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The authors present the case of a pediatric patient with a large coronary artery fistula from the aorta to the right atrium. Transcatheter closure with a 16 mm Amplatzer<span class="elsevierStyleSup">®</span> vascular plug II and a 6 mm Amplatzer<span class="elsevierStyleSup">®</span> duct occluder was performed, with complete occlusion.</p>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">As fístulas coronárias congénitas constituem uma patologia rara, frequentemente de diagnóstico acidental, por exemplo durante uma cirurgia cardíaca por outro motivo. A terapêutica pode ser conservadora, cirúrgica ou por intervenção percutânea, dependendo da experiência local ou da morfologia da fístula.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">É apresentado um caso de um paciente pediátrico com um diagnóstico de fístula coronária gigante da aorta com drenagem na aurícula direita. Foi efetuado encerramento percutâneo com um dispositivo Amplatzer<span class="elsevierStyleSup">®</span> Vascular Plug II de 16 mm e um dispositivo Amplatzer Duct Occluder de 6 mm, com oclusão total da fístula.</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" => 935 "Ancho" => 900 "Tamanyo" => 63561 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Aortogram with a 5 Fr pigtail angiographic catheter showing drainage of the fistula into the RA through two separate orifices.</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" => 901 "Ancho" => 900 "Tamanyo" => 66223 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Angiography in the fistula with the device still attached (arrow), showing drainage into the RA through a second orifice (arrowhead).</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" => 848 "Ancho" => 900 "Tamanyo" => 55831 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">With the duct occluder device in place (arrowhead), a residual shunt is seen through the second orifice (arrow).</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" => 943 "Ancho" => 900 "Tamanyo" => 64244 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Control angiography nine months after the second intervention. The fistula is closed (arrow) and the origin of the LAD and Cx arteries is clearly seen in two separate ostia (arrowheads). The devices are still in place, visible on the left.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Arterio-venous fistulas and related conditions" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S.A. Qureshi" 1 => "J.F. Reidy" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:4 [ "titulo" => "Paediatric cardiology" "paginaInicial" => "753" "paginaFinal" => "774" "serieFecha" => "2010" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Coronary artery fistulas: how to manage them" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "L.A. 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Levi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/ccd.20811" "Revista" => array:6 [ "tituloSerie" => "Catheter Cardiovasc Interv" "fecha" => "2006" "volumen" => "68" "paginaInicial" => "242" "paginaFinal" => "248" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16819766" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Management of coronary artery fistulae. Patient selection and results of transcatheter closure" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "L.R. Armsby" 1 => "J.F. Keane" 2 => "M.C. Sherwood" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "2002" "volumen" => "39" "paginaInicial" => "1026" "paginaFinal" => "1032" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11897446" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/08702551/0000003200000003/v1_201308021313/S0870255112003393/v1_201308021313/en/main.assets" "Apartado" => array:4 [ "identificador" => "362" "tipo" => "SECCION" "pt" => array:2 [ "titulo" => "Casos clínicos" "idiomaDefecto" => true ] "idiomaDefecto" => "pt" ] "PDF" => "https://static.elsevier.es/multimedia/08702551/0000003200000003/v1_201308021313/S0870255112003393/v1_201308021313/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255112003393?idApp=UINPBA00004E" ]
| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 12 | 7 | 19 |
| 2024 Outubro | 72 | 33 | 105 |
| 2024 Setembro | 69 | 24 | 93 |
| 2024 Agosto | 73 | 30 | 103 |
| 2024 Julho | 48 | 27 | 75 |
| 2024 Junho | 66 | 20 | 86 |
| 2024 Maio | 63 | 21 | 84 |
| 2024 Abril | 86 | 30 | 116 |
| 2024 Maro | 83 | 22 | 105 |
| 2024 Fevereiro | 67 | 24 | 91 |
| 2024 Janeiro | 81 | 27 | 108 |
| 2023 Dezembro | 67 | 21 | 88 |
| 2023 Novembro | 52 | 27 | 79 |
| 2023 Outubro | 37 | 17 | 54 |
| 2023 Setembro | 34 | 22 | 56 |
| 2023 Agosto | 61 | 19 | 80 |
| 2023 Julho | 25 | 8 | 33 |
| 2023 Junho | 38 | 12 | 50 |
| 2023 Maio | 57 | 26 | 83 |
| 2023 Abril | 23 | 2 | 25 |
| 2023 Maro | 31 | 33 | 64 |
| 2023 Fevereiro | 30 | 16 | 46 |
| 2023 Janeiro | 29 | 16 | 45 |
| 2022 Dezembro | 30 | 22 | 52 |
| 2022 Novembro | 44 | 27 | 71 |
| 2022 Outubro | 35 | 19 | 54 |
| 2022 Setembro | 31 | 27 | 58 |
| 2022 Agosto | 49 | 31 | 80 |
| 2022 Julho | 47 | 36 | 83 |
| 2022 Junho | 30 | 13 | 43 |
| 2022 Maio | 40 | 37 | 77 |
| 2022 Abril | 50 | 26 | 76 |
| 2022 Maro | 38 | 33 | 71 |
| 2022 Fevereiro | 42 | 27 | 69 |
| 2022 Janeiro | 42 | 25 | 67 |
| 2021 Dezembro | 31 | 33 | 64 |
| 2021 Novembro | 43 | 38 | 81 |
| 2021 Outubro | 41 | 37 | 78 |
| 2021 Setembro | 33 | 34 | 67 |
| 2021 Agosto | 30 | 30 | 60 |
| 2021 Julho | 25 | 24 | 49 |
| 2021 Junho | 22 | 17 | 39 |
| 2021 Maio | 33 | 26 | 59 |
| 2021 Abril | 55 | 38 | 93 |
| 2021 Maro | 77 | 12 | 89 |
| 2021 Fevereiro | 54 | 10 | 64 |
| 2021 Janeiro | 42 | 6 | 48 |
| 2020 Dezembro | 39 | 6 | 45 |
| 2020 Novembro | 43 | 10 | 53 |
| 2020 Outubro | 21 | 10 | 31 |
| 2020 Setembro | 53 | 6 | 59 |
| 2020 Agosto | 36 | 9 | 45 |
| 2020 Julho | 43 | 5 | 48 |
| 2020 Junho | 38 | 6 | 44 |
| 2020 Maio | 44 | 5 | 49 |
| 2020 Abril | 39 | 5 | 44 |
| 2020 Maro | 46 | 6 | 52 |
| 2020 Fevereiro | 124 | 10 | 134 |
| 2020 Janeiro | 40 | 6 | 46 |
| 2019 Dezembro | 44 | 9 | 53 |
| 2019 Novembro | 29 | 5 | 34 |
| 2019 Outubro | 50 | 11 | 61 |
| 2019 Setembro | 33 | 7 | 40 |
| 2019 Agosto | 26 | 5 | 31 |
| 2019 Julho | 39 | 15 | 54 |
| 2019 Junho | 27 | 7 | 34 |
| 2019 Maio | 47 | 10 | 57 |
| 2019 Abril | 30 | 11 | 41 |
| 2019 Maro | 113 | 8 | 121 |
| 2019 Fevereiro | 81 | 14 | 95 |
| 2019 Janeiro | 65 | 4 | 69 |
| 2018 Dezembro | 95 | 10 | 105 |
| 2018 Novembro | 136 | 10 | 146 |
| 2018 Outubro | 233 | 29 | 262 |
| 2018 Setembro | 73 | 19 | 92 |
| 2018 Agosto | 50 | 14 | 64 |
| 2018 Julho | 38 | 8 | 46 |
| 2018 Junho | 53 | 9 | 62 |
| 2018 Maio | 79 | 6 | 85 |
| 2018 Abril | 67 | 13 | 80 |
| 2018 Maro | 93 | 7 | 100 |
| 2018 Fevereiro | 42 | 5 | 47 |
| 2018 Janeiro | 73 | 3 | 76 |
| 2017 Dezembro | 93 | 12 | 105 |
| 2017 Novembro | 59 | 11 | 70 |
| 2017 Outubro | 64 | 15 | 79 |
| 2017 Setembro | 74 | 13 | 87 |
| 2017 Agosto | 41 | 13 | 54 |
| 2017 Julho | 31 | 9 | 40 |
| 2017 Junho | 50 | 13 | 63 |
| 2017 Maio | 48 | 10 | 58 |
| 2017 Abril | 58 | 26 | 84 |
| 2017 Maro | 41 | 11 | 52 |
| 2017 Fevereiro | 43 | 6 | 49 |
| 2017 Janeiro | 34 | 7 | 41 |
| 2016 Dezembro | 49 | 9 | 58 |
| 2016 Novembro | 64 | 15 | 79 |
| 2016 Outubro | 64 | 19 | 83 |
| 2016 Setembro | 36 | 11 | 47 |
| 2016 Agosto | 14 | 3 | 17 |
| 2016 Julho | 6 | 8 | 14 |
| 2016 Junho | 2 | 9 | 11 |
| 2016 Maio | 40 | 9 | 49 |
| 2016 Abril | 61 | 1 | 62 |
| 2016 Maro | 97 | 4 | 101 |
| 2016 Fevereiro | 119 | 24 | 143 |
| 2016 Janeiro | 90 | 10 | 100 |
| 2015 Dezembro | 94 | 10 | 104 |
| 2015 Novembro | 86 | 10 | 96 |
| 2015 Outubro | 105 | 13 | 118 |
| 2015 Setembro | 95 | 13 | 108 |
| 2015 Agosto | 97 | 19 | 116 |
| 2015 Julho | 71 | 8 | 79 |
| 2015 Junho | 57 | 5 | 62 |
| 2015 Maio | 74 | 9 | 83 |
| 2015 Abril | 68 | 13 | 81 |
| 2015 Maro | 63 | 10 | 73 |
| 2015 Fevereiro | 51 | 4 | 55 |
| 2015 Janeiro | 57 | 7 | 64 |
| 2014 Dezembro | 66 | 6 | 72 |
| 2014 Novembro | 74 | 11 | 85 |
| 2014 Outubro | 88 | 15 | 103 |
| 2014 Setembro | 68 | 16 | 84 |
| 2014 Agosto | 50 | 10 | 60 |
| 2014 Julho | 75 | 11 | 86 |
| 2014 Junho | 47 | 11 | 58 |
| 2014 Maio | 68 | 8 | 76 |
| 2014 Abril | 65 | 11 | 76 |
| 2014 Maro | 75 | 17 | 92 |
| 2014 Fevereiro | 51 | 18 | 69 |
| 2014 Janeiro | 74 | 16 | 90 |
| 2013 Dezembro | 63 | 12 | 75 |
| 2013 Novembro | 67 | 21 | 88 |
| 2013 Outubro | 49 | 20 | 69 |
| 2013 Setembro | 50 | 26 | 76 |
| 2013 Agosto | 66 | 20 | 86 |
| 2013 Julho | 85 | 34 | 119 |
| 2013 Junho | 49 | 15 | 64 |
| 2013 Maio | 63 | 32 | 95 |
| 2013 Abril | 99 | 56 | 155 |
| 2013 Maro | 45 | 34 | 79 |
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