Case report
Transient ST-segment elevation and chest pain following percutaneous mitral valvuloplasty
Elevação transitória do segmento ST associada a dor torácica na sequência de valvuloplastia mitral percutânea
Juan Ruiz-García
, Javier Soriano
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Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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"tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "431" "paginaFinal" => "435" ] ] "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" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2340 "Ancho" => 3024 "Tamanyo" => 520595 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Left: result of pace-mapping; right: baseline PVC and spontaneous ventricular tachycardia.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Moisés Rodríguez-Mañero, Fatih Bayrak, Mehdi Namdar, Rubén Casado-Arroyo, Danilo Ricciardi, Gian-Battista Chierchia, Andrea Sarkozy, Carlo de Asmundis, Pedro Brugada" "autores" => array:9 [ 0 => array:2 [ "nombre" => "Moisés" "apellidos" => "Rodríguez-Mañero" ] 1 => array:2 [ "nombre" => "Fatih" "apellidos" => "Bayrak" ] 2 => array:2 [ "nombre" => "Mehdi" "apellidos" => "Namdar" ] 3 => array:2 [ "nombre" => "Rubén" "apellidos" => "Casado-Arroyo" ] 4 => array:2 [ "nombre" => "Danilo" "apellidos" => "Ricciardi" ] 5 => array:2 [ "nombre" => "Gian-Battista" "apellidos" => "Chierchia" ] 6 => array:2 [ "nombre" => "Andrea" "apellidos" => "Sarkozy" ] 7 => array:2 [ "nombre" => "Carlo" "apellidos" => "de Asmundis" ] 8 => array:2 [ "nombre" => "Pedro" "apellidos" => "Brugada" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255113000796?idApp=UINPBA00004E" "url" => "/08702551/0000003200000005/v1_201308021350/S0870255113000796/v1_201308021350/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Transient ST-segment elevation and chest pain following percutaneous mitral valvuloplasty" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "437" "paginaFinal" => "439" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Juan Ruiz-García, Javier Soriano" "autores" => array:2 [ 0 => array:4 [ "nombre" => "Juan" "apellidos" => "Ruiz-García" "email" => array:1 [ 0 => "j.ruizgarcia@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Javier" "apellidos" => "Soriano" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "*" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Elevação transitória do segmento ST associada a dor torácica na sequência de valvuloplastia mitral percutânea" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1002 "Ancho" => 3000 "Tamanyo" => 193256 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A) Percutaneous mitral valvuloplasty following the Inoue technique. Last balloon inflation to 30<span class="elsevierStyleHsp" style=""></span>mm; (B) right coronary angiogram performed during angina and inferior ST-segment elevation; (C) left coronary angiogram performed during angina and inferior ST-segment elevation.</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">The most frequent risks associated with percutaneous mitral valvuloplasty (PMV) are cardiac tamponade and systemic embolism related to transseptal puncture and manipulation of catheters or wires inside the cardiac chambers, and increases in mitral regurgitation after balloon inflation.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> We present an uncommon and less understood complication of this procedure.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 55-year-old Caucasian man was admitted to our hospital complaining of dyspnea and edema of ten days’ duration. Two years before, he had had a first episode of atrial fibrillation (AF) and was diagnosed with moderate mitral stenosis at that time. Although he had been asymptomatic, anticoagulated and in sinus rhythm in recent months, the patient was once more in AF with fast ventricular response (110–120<span class="elsevierStyleHsp" style=""></span>bpm) that required high doses of beta-blockers and digoxin to control. The echocardiogram now showed a rheumatic mitral valve with a mean gradient of 6<span class="elsevierStyleHsp" style=""></span>mmHg, an area of 1.2<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span> and a Wilkins score of 6. In the absence of formal contraindications, PMV following the Inoue technique was performed with a 28-mm balloon (patient's height 165<span class="elsevierStyleHsp" style=""></span>cm). There were no complications during septal puncture (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A), so the balloon was inflated initially to 28<span class="elsevierStyleHsp" style=""></span>mm four times and for the last time to 30<span class="elsevierStyleHsp" style=""></span>mm (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>A). Immediately following the final inflation, a new ST-segment elevation in the inferior leads was recorded on the ECG and the patient started complaining of severe chest pain. His blood pressure also dropped significantly (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>B), and intravenous phenylephrine was administered to normalize it. At this time, as the patient's angina was worsening, it was decided to perform coronary angiography. After intracoronary nitroglycerin administration (200<span class="elsevierStyleHsp" style=""></span>μg), though the ST segment remained elevated (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>C), coronary angiograms showed right coronary dominance with TIMI flow grade 3 and no significant lesion, spasm, thrombus or air embolism (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>B and C). A few minutes later the condition resolved (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>D) and did not recur. During hospital stay there were no more complications and the patient was discharged with a transmitral mean gradient of 3<span class="elsevierStyleHsp" style=""></span>mmHg and mild mitral regurgitation, and without documented myocardial injury (maximum troponin T 0.03<span class="elsevierStyleHsp" style=""></span>ng/ml and no wall motion abnormalities on the echocardiogram).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">In an international series of PMVs published some years ago, Vahanian et al.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> described transient inferior ST-segment elevation with no or minor chest pain after Inoue balloon deflation in 10 patients (2.6%). The right coronary artery presented no abnormalities, so they attributed the episodes to air microembolisms. In another series of 108 PMVs, Ludman et al.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> identified eight patients (7.4%) with transient inferior ST-segment elevation just after crossing the interatrial septum with the balloon but before any inflation. Seven patients reported angina but there were no changes in blood pressure. Symptoms resolved after 1–2<span class="elsevierStyleHsp" style=""></span>minutes and right coronary angiography performed in three patients showed no spasm or thrombus, so the authors rejected microembolism as a cause and subsequently proposed a neurally-mediated mechanism.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Our case presents several differences from previous reports. The patient was very symptomatic (severe angina and blood pressure drop), and ST-segment elevation persisted for more than seven minutes. In addition, heart rate did not decrease in parallel with blood pressure, so we consider vagal stimulus unlikely. Coronary embolism is also questionable as no significant elevation in troponin T levels was observed in the following days and coronary flow during angina and ST-segment elevation was completely normal. So given the absence of spasm on the angiogram (although this cannot be totally excluded), we suggest that mechanical myocardial compression induced by repeated inflations and overinflation of a 28-mm balloon to 30<span class="elsevierStyleHsp" style=""></span>mm might have led to transient transmural ischemia in the inferior basal segments. This mechanism might be responsible for some of the ST-segment changes observed during PMV and other percutaneous interventions.</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="par0025" 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="par0030" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data and that all the patients included in the study received sufficient information and gave their written informed consent to participate in the study.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Right to privacy and informed consent</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">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" => "xres251301" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec238898" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres251300" "titulo" => "Resumo" ] 3 => array:2 [ "identificador" => "xpalclavsec238899" "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:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-07-16" "fechaAceptado" => "2012-09-04" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec238898" "palabras" => array:4 [ 0 => "Complications" 1 => "Angina" 2 => "Rheumatic disease" 3 => "Hypotension" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec238899" "palabras" => array:4 [ 0 => "Complicações" 1 => "Angina" 2 => "Doença reumática" 3 => "Hipotensão" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Transient ST-segment elevation occurring in the context of percutaneous cardiac interventions has not been fully characterized. We present a case of an inferior ST-segment elevation associated with angina and hypotension following percutaneous mitral valvuloplasty. Coronary angiography during ST elevation found no abnormalities and no myocardial necrosis was documented. Thus, as the Inoue balloon had been reinflated and overinflated, we suggest that mechanical myocardial compression might be responsible for the transmural transient ischemia observed in some cardiac percutaneous procedures involving balloons or closure devices.</p>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Elevaçãotransitória do segmento ST ocorrem no contexto de intervençõespercutâneas cardíacas nãofoi completamente caracterizado. Apresentamosum caso de umaelevação inferior do segmento ST associadacom angina e hipotensãoapós plastia mitral percutânea. A coronariografia durante a elevação do ST nãoencontrou anormalidades e sem necrose miocárdica foi documentada. Assim, quando o balão de Inouetinha sido reinflated e inflacionado, sugerimos que a compressãomecânica do miocárdio pode ser responsável pela isquemia transiente transmural observada emalgunsprocedimentospercutâneos cardíacas envolvendobalõesou dispositivos de fecho.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1715 "Ancho" => 2500 "Tamanyo" => 539834 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Electrocardiogram and invasive blood pressure (BP) records during percutaneous mitral valvuloplasty (PMV). (A) Isoelectric ST segment and normal BP before performing PMV; (B) after last balloon inflation to 30<span class="elsevierStyleHsp" style=""></span>mm, a new ST-segment elevation in lead II accompanied by significant BP drop is recorded; (C) intravenous phenylephrine was required to normalize BP, but the ST segment remained elevated so coronary angiography was performed at this time; (D) the condition resolved spontaneously in a few minutes, the ST segment and BP returning to baseline levels.</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" => 1002 "Ancho" => 3000 "Tamanyo" => 193256 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A) Percutaneous mitral valvuloplasty following the Inoue technique. Last balloon inflation to 30<span class="elsevierStyleHsp" style=""></span>mm; (B) right coronary angiogram performed during angina and inferior ST-segment elevation; (C) left coronary angiogram performed during angina and inferior ST-segment elevation.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Percutaneous balloon mitral valvuloplasty: a review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:8 [ 0 => "M. Nobuyoshi" 1 => "T. Arita" 2 => "S. Shirai" 3 => "N. Hamasaki" 4 => "H. Yokoi" 5 => "M. Iwabuchi" 6 => "H. Yasumoto" 7 => "H. Nosaka" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/CIRCULATIONAHA.108.792952" "Revista" => array:6 [ "tituloSerie" => "Circulation" "fecha" => "2009" "volumen" => "119" "paginaInicial" => "e211" "paginaFinal" => "e219" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19106383" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Percutaneous transvenous mitral commissurotomy using the Inoue balloon: international experience" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. Vahanian" 1 => "B. Cormier" 2 => "B. 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Shapiro" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Cardiol" "fecha" => "1997" "volumen" => "79" "paginaInicial" => "1704" "paginaFinal" => "1705" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9202372" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Inferior ST-segment elevation following transseptal puncture for balloon mitral valvuloplasty is atropine-responsive" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "D.J. Hildick-Smith" 1 => "P.F. Ludman" 2 => "L.M. Shapiro" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Invasive Cardiol" "fecha" => "2004" "volumen" => "16" "paginaInicial" => "1" "paginaFinal" => "2" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23570200" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/08702551/0000003200000005/v1_201308021350/S0870255113000784/v1_201308021350/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/08702551/0000003200000005/v1_201308021350/S0870255113000784/v1_201308021350/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255113000784?idApp=UINPBA00004E" ]
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|---|---|---|---|
| 2024 Novembro | 12 | 7 | 19 |
| 2024 Outubro | 35 | 34 | 69 |
| 2024 Setembro | 59 | 25 | 84 |
| 2024 Agosto | 64 | 39 | 103 |
| 2024 Julho | 42 | 40 | 82 |
| 2024 Junho | 47 | 22 | 69 |
| 2024 Maio | 47 | 22 | 69 |
| 2024 Abril | 41 | 31 | 72 |
| 2024 Maro | 34 | 20 | 54 |
| 2024 Fevereiro | 30 | 25 | 55 |
| 2024 Janeiro | 28 | 32 | 60 |
| 2023 Dezembro | 28 | 26 | 54 |
| 2023 Novembro | 34 | 30 | 64 |
| 2023 Outubro | 30 | 16 | 46 |
| 2023 Setembro | 25 | 16 | 41 |
| 2023 Agosto | 30 | 20 | 50 |
| 2023 Julho | 28 | 11 | 39 |
| 2023 Junho | 18 | 13 | 31 |
| 2023 Maio | 36 | 27 | 63 |
| 2023 Abril | 16 | 1 | 17 |
| 2023 Maro | 24 | 27 | 51 |
| 2023 Fevereiro | 28 | 18 | 46 |
| 2023 Janeiro | 17 | 12 | 29 |
| 2022 Dezembro | 34 | 24 | 58 |
| 2022 Novembro | 51 | 24 | 75 |
| 2022 Outubro | 31 | 19 | 50 |
| 2022 Setembro | 26 | 39 | 65 |
| 2022 Agosto | 30 | 40 | 70 |
| 2022 Julho | 33 | 33 | 66 |
| 2022 Junho | 24 | 20 | 44 |
| 2022 Maio | 30 | 41 | 71 |
| 2022 Abril | 37 | 32 | 69 |
| 2022 Maro | 28 | 41 | 69 |
| 2022 Fevereiro | 26 | 18 | 44 |
| 2022 Janeiro | 26 | 29 | 55 |
| 2021 Dezembro | 26 | 30 | 56 |
| 2021 Novembro | 39 | 42 | 81 |
| 2021 Outubro | 36 | 42 | 78 |
| 2021 Setembro | 25 | 27 | 52 |
| 2021 Agosto | 37 | 33 | 70 |
| 2021 Julho | 26 | 23 | 49 |
| 2021 Junho | 20 | 19 | 39 |
| 2021 Maio | 32 | 29 | 61 |
| 2021 Abril | 49 | 50 | 99 |
| 2021 Maro | 83 | 17 | 100 |
| 2021 Fevereiro | 48 | 14 | 62 |
| 2021 Janeiro | 40 | 18 | 58 |
| 2020 Dezembro | 27 | 20 | 47 |
| 2020 Novembro | 41 | 18 | 59 |
| 2020 Outubro | 29 | 18 | 47 |
| 2020 Setembro | 68 | 19 | 87 |
| 2020 Agosto | 34 | 15 | 49 |
| 2020 Julho | 27 | 18 | 45 |
| 2020 Junho | 38 | 10 | 48 |
| 2020 Maio | 38 | 4 | 42 |
| 2020 Abril | 27 | 9 | 36 |
| 2020 Maro | 40 | 9 | 49 |
| 2020 Fevereiro | 62 | 17 | 79 |
| 2020 Janeiro | 26 | 9 | 35 |
| 2019 Dezembro | 37 | 11 | 48 |
| 2019 Novembro | 26 | 7 | 33 |
| 2019 Outubro | 40 | 3 | 43 |
| 2019 Setembro | 23 | 11 | 34 |
| 2019 Agosto | 22 | 5 | 27 |
| 2019 Julho | 33 | 9 | 42 |
| 2019 Junho | 27 | 10 | 37 |
| 2019 Maio | 34 | 9 | 43 |
| 2019 Abril | 19 | 14 | 33 |
| 2019 Maro | 43 | 13 | 56 |
| 2019 Fevereiro | 46 | 16 | 62 |
| 2019 Janeiro | 19 | 5 | 24 |
| 2018 Dezembro | 41 | 18 | 59 |
| 2018 Novembro | 93 | 17 | 110 |
| 2018 Outubro | 159 | 22 | 181 |
| 2018 Setembro | 59 | 13 | 72 |
| 2018 Agosto | 59 | 15 | 74 |
| 2018 Julho | 34 | 10 | 44 |
| 2018 Junho | 49 | 5 | 54 |
| 2018 Maio | 72 | 8 | 80 |
| 2018 Abril | 76 | 5 | 81 |
| 2018 Maro | 75 | 12 | 87 |
| 2018 Fevereiro | 50 | 5 | 55 |
| 2018 Janeiro | 78 | 10 | 88 |
| 2017 Dezembro | 64 | 14 | 78 |
| 2017 Novembro | 38 | 5 | 43 |
| 2017 Outubro | 29 | 10 | 39 |
| 2017 Setembro | 49 | 11 | 60 |
| 2017 Agosto | 42 | 14 | 56 |
| 2017 Julho | 29 | 16 | 45 |
| 2017 Junho | 46 | 24 | 70 |
| 2017 Maio | 58 | 23 | 81 |
| 2017 Abril | 34 | 6 | 40 |
| 2017 Maro | 52 | 31 | 83 |
| 2017 Fevereiro | 29 | 18 | 47 |
| 2017 Janeiro | 25 | 9 | 34 |
| 2016 Dezembro | 20 | 5 | 25 |
| 2016 Novembro | 22 | 8 | 30 |
| 2016 Outubro | 28 | 10 | 38 |
| 2016 Setembro | 18 | 9 | 27 |
| 2016 Agosto | 12 | 3 | 15 |
| 2016 Julho | 6 | 4 | 10 |
| 2016 Junho | 2 | 6 | 8 |
| 2016 Maio | 30 | 5 | 35 |
| 2016 Abril | 21 | 3 | 24 |
| 2016 Maro | 41 | 7 | 48 |
| 2016 Fevereiro | 50 | 15 | 65 |
| 2016 Janeiro | 45 | 8 | 53 |
| 2015 Dezembro | 58 | 10 | 68 |
| 2015 Novembro | 36 | 7 | 43 |
| 2015 Outubro | 54 | 13 | 67 |
| 2015 Setembro | 51 | 8 | 59 |
| 2015 Agosto | 57 | 10 | 67 |
| 2015 Julho | 39 | 6 | 45 |
| 2015 Junho | 28 | 4 | 32 |
| 2015 Maio | 45 | 18 | 63 |
| 2015 Abril | 51 | 7 | 58 |
| 2015 Maro | 39 | 6 | 45 |
| 2015 Fevereiro | 42 | 7 | 49 |
| 2015 Janeiro | 41 | 3 | 44 |
| 2014 Dezembro | 41 | 12 | 53 |
| 2014 Novembro | 38 | 10 | 48 |
| 2014 Outubro | 45 | 9 | 54 |
| 2014 Setembro | 44 | 10 | 54 |
| 2014 Agosto | 38 | 10 | 48 |
| 2014 Julho | 53 | 10 | 63 |
| 2014 Junho | 42 | 4 | 46 |
| 2014 Maio | 49 | 9 | 58 |
| 2014 Abril | 66 | 11 | 77 |
| 2014 Maro | 102 | 11 | 113 |
| 2014 Fevereiro | 89 | 17 | 106 |
| 2014 Janeiro | 91 | 12 | 103 |
| 2013 Dezembro | 147 | 19 | 166 |
| 2013 Novembro | 76 | 13 | 89 |
| 2013 Outubro | 56 | 11 | 67 |
| 2013 Setembro | 54 | 15 | 69 |
| 2013 Agosto | 69 | 23 | 92 |
| 2013 Julho | 68 | 25 | 93 |
| 2013 Junho | 50 | 24 | 74 |
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