Case report
Post-cardiac injury syndrome following transvenous pacing: Case report
Síndrome pós lesão cardíaca após pacing transvenoso – a propósito de um caso clínico
Carla Sousa
, Elisabete Martins, Manuel Campelo, Inês Rangel, Pedro B. Almeida, Maria Júlia Maciel
Autor para correspondência
Serviço de Cardiologia, Centro Hospitalar São João, E.P.E., Porto, Portugal
Lido
7438
Vezesque se leu este artigo
1754
Total PDF
5684
Total HTML
Compartilhar estatísticas
array:25 [ "pii" => "S0870255114001061" "issn" => "08702551" "doi" => "10.1016/j.repc.2013.12.005" "estado" => "S300" "fechaPublicacion" => "2014-05-01" "aid" => "466" "copyright" => "Sociedade Portuguesa de Cardiologia" "copyrightAnyo" => "2013" "documento" => "simple-article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Rev Port Cardiol. 2014;33:307.e1-4" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 3966 "formatos" => array:3 [ "EPUB" => 186 "HTML" => 3124 "PDF" => 656 ] ] "Traduccion" => array:1 [ "en" => array:20 [ "pii" => "S2174204914001251" "issn" => "21742049" "doi" => "10.1016/j.repce.2013.12.002" "estado" => "S300" "fechaPublicacion" => "2014-05-01" "aid" => "466" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "simple-article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Rev Port Cardiol. 2014;33:307.e1-4" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 3758 "formatos" => array:3 [ "EPUB" => 159 "HTML" => 2997 "PDF" => 602 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Post-cardiac injury syndrome following transvenous pacing: Case report" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "307.e1" "paginaFinal" => "307.e4" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Síndrome pós lesão cardíaca após <span class="elsevierStyleItalic">pacing</span> transvenoso – a propósito de um caso clínico" ] ] "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" => 884 "Ancho" => 3001 "Tamanyo" => 186819 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Echocardiographic subcostal views: (A) after permanent pacemaker implantation revealing a new moderate pericardial effusion (arrow); (B) at hospital discharge, after a few days of clinical surveillance with no evidence of pericardial effusion (arrow); and (C) at readmission, with a large pericardial effusion and ‘swinging heart’ (arrow).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Carla Sousa, Elisabete Martins, Manuel Campelo, Inês Rangel, Pedro B. Almeida, Maria Júlia Maciel" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Carla" "apellidos" => "Sousa" ] 1 => array:2 [ "nombre" => "Elisabete" "apellidos" => "Martins" ] 2 => array:2 [ "nombre" => "Manuel" "apellidos" => "Campelo" ] 3 => array:2 [ "nombre" => "Inês" "apellidos" => "Rangel" ] 4 => array:2 [ "nombre" => "Pedro B." "apellidos" => "Almeida" ] 5 => array:2 [ "nombre" => "Maria Júlia" "apellidos" => "Maciel" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0870255114001061" "doi" => "10.1016/j.repc.2013.12.005" "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/S0870255114001061?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204914001251?idApp=UINPBA00004E" "url" => "/21742049/0000003300000005/v1_201407070904/S2174204914001251/v1_201407070904/en/main.assets" ] ] "itemSiguiente" => array:20 [ "pii" => "S0870255114000730" "issn" => "08702551" "doi" => "10.1016/j.repc.2014.01.011" "estado" => "S300" "fechaPublicacion" => "2014-05-01" "aid" => "447" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "simple-article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Rev Port Cardiol. 2014;33:309.e1-7" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 5122 "formatos" => array:3 [ "EPUB" => 155 "HTML" => 3989 "PDF" => 978 ] ] "pt" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Caso clínico</span>" "titulo" => "Terapêutica de ressincronização cardíaca e efeito pró‐arrítmico: um problema que deve ser lembrado" "tienePdf" => "pt" "tieneTextoCompleto" => "pt" "tieneResumen" => array:2 [ 0 => "pt" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "309.e1" "paginaFinal" => "309.e7" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "The proarrhythmic effect of cardiac resynchronization therapy: An issue that should be borne in mind" ] ] "contieneResumen" => array:2 [ "pt" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "pt" => true ] "contienePdf" => array:1 [ "pt" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figura 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1075 "Ancho" => 1033 "Tamanyo" => 94889 ] ] "descripcion" => array:1 [ "pt" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Radiografia de tórax (AP). Seta azul: eletrocateter em veia posterior. Seta vermelha: eletrocateter epicárdico em posição lateral.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Nuno Cabanelas, Mário Oliveira, Manuel Nogueira da Silva, Pedro Cunha, Bruno Valente, Ana Lousinha, Sofia Santos, Luísa Branco, Rui Ferreira" "autores" => array:9 [ 0 => array:2 [ "nombre" => "Nuno" "apellidos" => "Cabanelas" ] 1 => array:2 [ "nombre" => "Mário" "apellidos" => "Oliveira" ] 2 => array:2 [ "nombre" => "Manuel" "apellidos" => "Nogueira da Silva" ] 3 => array:2 [ "nombre" => "Pedro" "apellidos" => "Cunha" ] 4 => array:2 [ "nombre" => "Bruno" "apellidos" => "Valente" ] 5 => array:2 [ "nombre" => "Ana" "apellidos" => "Lousinha" ] 6 => array:2 [ "nombre" => "Sofia" "apellidos" => "Santos" ] 7 => array:2 [ "nombre" => "Luísa" "apellidos" => "Branco" ] 8 => array:2 [ "nombre" => "Rui" "apellidos" => "Ferreira" ] ] ] ] ] "idiomaDefecto" => "pt" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2174204914001226" "doi" => "10.1016/j.repce.2014.01.006" "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/S2174204914001226?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255114000730?idApp=UINPBA00004E" "url" => "/08702551/0000003300000005/v1_201406210043/S0870255114000730/v1_201406210043/pt/main.assets" ] "itemAnterior" => array:20 [ "pii" => "S0870255114000456" "issn" => "08702551" "doi" => "10.1016/j.repc.2014.01.010" "estado" => "S300" "fechaPublicacion" => "2014-05-01" "aid" => "433" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "simple-article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Rev Port Cardiol. 2014;33:305.e1-7" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 6123 "formatos" => array:3 [ "EPUB" => 184 "HTML" => 5074 "PDF" => 865 ] ] "pt" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Caso clínico</span>" "titulo" => "Ablação epicárdica para prevenção da fibrilhação ventricular em doente com síndrome de Brugada" "tienePdf" => "pt" "tieneTextoCompleto" => "pt" "tieneResumen" => array:2 [ 0 => "pt" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "305.e1" "paginaFinal" => "305.e7" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Epicardial ablation for prevention of ventricular fibrillation in a patient with Brugada Syndrome" ] ] "contieneResumen" => array:2 [ "pt" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "pt" => true ] "contienePdf" => array:1 [ "pt" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1026 "Ancho" => 2499 "Tamanyo" => 176163 ] ] "descripcion" => array:1 [ "pt" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Mapas endocárdicos do ventrículo direito. Mapeamento do tempo decorrido até ao término do eletrograma bipolar local, com representação das vistas ântero‐posterior (<span class="elsevierStyleItalic">A</span>) e lateral direita (<span class="elsevierStyleItalic">B</span>): ativação endocárdica das regiões endocárdicas terminou no decurso do QRS de superfície (este terminou 127 ms após a referência do mapa), estando as mesmas coloridas a vermelho. Mapeamento da voltagem bipolar, com representação das vistas ântero‐posterior (<span class="elsevierStyleItalic">C</span>) e lateral direita (<span class="elsevierStyleItalic">D</span>): todas as regiões endocárdicas do ventrículo direito exibiram voltagem normal (> 1,5 mV), estando as mesmas coloridas a rosa.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Nuno Cortez‐Dias, Rui Plácido, Liliana Marta, Ana Bernardes, Sílvia Sobral, Luís Carpinteiro, João de Sousa" "autores" => array:7 [ 0 => array:2 [ "nombre" => "Nuno" "apellidos" => "Cortez‐Dias" ] 1 => array:2 [ "nombre" => "Rui" "apellidos" => "Plácido" ] 2 => array:2 [ "nombre" => "Liliana" "apellidos" => "Marta" ] 3 => array:2 [ "nombre" => "Ana" "apellidos" => "Bernardes" ] 4 => array:2 [ "nombre" => "Sílvia" "apellidos" => "Sobral" ] 5 => array:2 [ "nombre" => "Luís" "apellidos" => "Carpinteiro" ] 6 => array:2 [ "nombre" => "João" "apellidos" => "de Sousa" ] ] ] ] ] "idiomaDefecto" => "pt" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2174204914001196" "doi" => "10.1016/j.repce.2014.01.005" "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/S2174204914001196?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255114000456?idApp=UINPBA00004E" "url" => "/08702551/0000003300000005/v1_201406210043/S0870255114000456/v1_201406210043/pt/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Post-cardiac injury syndrome following transvenous pacing: Case report" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "307.e1" "paginaFinal" => "307.e4" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Carla Sousa, Elisabete Martins, Manuel Campelo, Inês Rangel, Pedro B. Almeida, Maria Júlia Maciel" "autores" => array:6 [ 0 => array:4 [ "nombre" => "Carla" "apellidos" => "Sousa" "email" => array:1 [ 0 => "cmcsousa@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Elisabete" "apellidos" => "Martins" ] 2 => array:2 [ "nombre" => "Manuel" "apellidos" => "Campelo" ] 3 => array:2 [ "nombre" => "Inês" "apellidos" => "Rangel" ] 4 => array:2 [ "nombre" => "Pedro B." "apellidos" => "Almeida" ] 5 => array:2 [ "nombre" => "Maria Júlia" "apellidos" => "Maciel" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Serviço de Cardiologia, Centro Hospitalar São João, E.P.E., Porto, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Síndrome pós lesão cardíaca após <span class="elsevierStyleItalic">pacing</span> transvenoso – a propósito de um caso clínico" ] ] "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" => 530 "Ancho" => 1800 "Tamanyo" => 90512 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Echocardiographic subcostal views: (A) after permanent pacemaker implantation revealing a new moderate pericardial effusion (arrow); (B) at hospital discharge, after a few days of clinical surveillance with no evidence of pericardial effusion (arrow); and (C) at readmission, with a large pericardial effusion and ‘swinging heart’ (arrow).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Pacemaker implantation is a classic technique in cardiology. Materials have changed considerably in recent years, making the procedure safer and the indications broader. However, as in all invasive procedures, there is the risk of immediate and delayed intra and postoperative complications, such as system infection, lead displacement and post-cardiac injury syndrome (PCIS).</p><p id="par0010" class="elsevierStylePara elsevierViewall">We report a rare case of an iatrogenic cardiac rupture followed by PCIS with delayed pericardial effusion after a pacemaker implantation. A comprehensive literature review on this topic is provided.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0020" class="elsevierStylePara elsevierViewall">An 89-year-old woman was admitted for syncope. She had a history of hypertension and dyslipidemia.</p><p id="par0025" class="elsevierStylePara elsevierViewall">At admission, she reported a brief episode of loss of consciousness, without prodromes or head trauma and with spontaneous recovery. Her physical examination revealed bradycardia but no other relevant findings. The electrocardiogram showed advanced heart block with mean heart rate of 30 bpm. She was not under any negative chronotropic medication and laboratory tests showed no relevant electrolyte disturbances. Summary echocardiography revealed mild systolic dysfunction without pericardial effusion.</p><p id="par0030" class="elsevierStylePara elsevierViewall">A temporary pacemaker was inserted via the right femoral vein, without immediate complications, followed by implantation of a dual chamber permanent pacemaker the next day. During this procedure, the patient presented a brief period of hypotension and pleuritic chest pain. The echocardiogram showed moderate systolic dysfunction and new moderate pericardial effusion (16 mm), with no signs of hemodynamic compromise (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). A diagnosis of iatrogenic right ventricle rupture was made and the patient was kept under clinical, electrical and echocardiographic monitoring. She presented progressive reduction of the pericardial effusion and was discharged by the 5th day, asymptomatic and without pericardial effusion (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Four weeks later, she was readmitted for pleuritic chest pain and asthenia. Physical examination revealed reduced heart sounds with no other significant alterations, including in the pacemaker scar, which presented no inflammatory signs. The electrocardiogram showed sinus rhythm with P-wave synchronous ventricular pacing. Blood tests showed leukocytosis (17×10<span class="elsevierStyleSup">9</span>/l) and elevated C-reactive protein (CRP) (110 mg/dl), with no evidence of systemic infection or fever. Blood cultures were negative and the chest X-ray showed cardiomegaly without pleural effusion. The echocardiogram revealed a large pericardial effusion (25 mm), with ‘swinging heart’ and signs of hemodynamic compromise (inferior vena cava dilatation, mitral and tricuspid flow variation >50%, abnormal septal motion, mild diastolic compression of right heart chambers), suggestive of incipient tamponade physiology (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>).</p><p id="par0040" class="elsevierStylePara elsevierViewall">Pericardiocentesis was performed, with drainage of 350 ml of light yellow fluid, which was found to be a sterile exudate (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Post-procedural echocardiography still showed moderate pericardial effusion (18 mm), but with no signs of hemodynamic compromise. Autoimmunity study was negative. There was no sign of pacemaker dysfunction, sensing and pacing thresholds being optimal.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The patient was diagnosed with PCIS and medicated with aspirin (500 mg four times a day) and colchicine (1 mg twice a day). As there was no favorable clinical evolution or remission of the pericardial effusion, prednisolone was added on the seventh day (1 mg/kg/day), with eventual resolution of symptoms, laboratory parameters and pericardial effusion. She was discharged on the 15th day and remained asymptomatic at follow-up.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">PCIS is an inflammatory process involving the pleura (pleural effusion) and/or pericardium (pericarditis, pericardial effusion) secondary to cardiac injury.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It can develop after cardiac trauma, cardiac surgery, myocardial infarction and certain intravascular procedures, including transvenous pacemaker lead insertion, electrophysiological studies and percutaneous coronary interventions, even in the absence of obvious cardiac perforation.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Hence, the designation of PCIS covers post-myocardial infarction pericarditis (Dressler syndrome), post-pericardiotomy syndrome and post-traumatic pericarditis. In the setting of cardiac pacing, it appears to be a very rare condition, with only a few cases described in the literature.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Unlike acute myocardial rupture and acute pericarditis, which can both occur within 24 hours of transvenous pacing, PCIS typically occurs later on and represents an exclusion diagnosis.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Although the precise cause is not clear, it appears to be due to an immune reaction precipitated by pacemaker-induced myocardial injury (late autoimmune or inflammatory response to pericardial irritation by minimally protruding electrodes, by low-grade bleeding with hemorrhagic pericarditis or by acute cardiac perforation). The underlying molecular mechanism may be similar to that of Dressler syndrome.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> There is no known predisposing underlying cardiac disease and the only demographic predictor seems to be advanced age.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The potential role of technical factors (such as active fixation during lead positioning or previous temporary transvenous pacemaker use) in the development of PCIS has been postulated but needs further investigation.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,4</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Clinical presentation includes pleuritic chest pain, shortness of breath and low-grade fever, symptoms that generally occur within the first month after the procedure.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> A rub (pericardial or pleural) may be detected and non-specific ECG changes can be found.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">On admission, elevated sedimentation rates and CRP levels, sometimes with both pericardial and pleural effusions, are typically documented. Laboratory analysis usually reveals exudative effusions.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Other documented laboratory alterations include unexplained falls in hemoglobin, low complement levels, presence of immune complexes in the pleural fluid and elevated anti-myocardial antibody levels in both serum and pleural effusion.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Regarding differential diagnosis, clinical entities such as infectious pericardial effusion, viral pericarditis and delayed perforation must be ruled out. In this setting, clinical history, electrocardiography, pacemaker interrogation, cardiac imaging techniques and pericardial fluid analysis are crucial diagnostic tools. Previous history of viral infection and diffuse ST-segment elevation are highly suggestive of acute viral pericarditis. The presence of a light yellow pericardial effusion excludes delayed myocardial lead rupture. Echocardiography and computed tomography can show pericardial positioning of a pacemaker lead, which, as well as pacemaker dysfunction, suggests late cardiac rupture.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Finally, pericardial effusion associated with infection of the pacemaker implantation site suggests a bacterial etiology and endocarditis must be ruled out.</p><p id="par0085" class="elsevierStylePara elsevierViewall">If identified early, these patients will likely respond to NSAIDS, colchicine and/or prednisone, and medical treatment may eliminate the need for a surgical procedure.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> However, cases of large fluid volumes, recurrent fluid accumulation and/or tamponade physiology require pericardial fluid drainage and/or pericardial window at presentation.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Regardless of the possible need for an invasive strategy in the acute phase, the outcome after PCIS secondary to pacemaker implantation is favorable, as all the reported cases presented a good evolution, even though there may be recurrence. However, delayed diagnosis and treatment of PCIS, as well as unnecessary tests to screen for other causes of pericardial or pleural effusion and fever, may prolong hospital stay and increase medical costs.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">In the reported case an iatrogenic cardiac rupture immediately after permanent pacemaker implantation was followed by a hemodynamically significant pericardial effusion requiring urgent pericardiocentesis. Bacterial infection of the pacemaker implantation site and infective endocarditis were excluded, as was delayed myocardial perforation. The clinical features, investigation and response to steroids indicated a diagnosis of PCIS.</p><p id="par0100" class="elsevierStylePara elsevierViewall">This case highlights the need for a high suspicion index in the diagnosis of this rare entity after interventional procedures. Early recognition is crucial, both in order to proceed to the appropriate therapy and to prevent catastrophic complications, as well as to avoid prolonged hospital stay and increased medical costs.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0105" class="elsevierStylePara elsevierViewall">PCIS after pacemaker implantation is a rare situation with potentially serious complications. It constitutes an exclusion diagnosis in which a high suspicion index is necessary. The case described highlights the need to keep this entity in mind in patients who have undergone invasive cardiac procedures.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Protection of human and animal subjects</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Confidentiality of data</span><p id="par0115" 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="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Right to privacy and informed consent</span><p id="par0120" 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="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflicts of interest</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:2 [ "identificador" => "xres347622" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec329290" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres347623" "titulo" => "Resumo" ] 3 => array:2 [ "identificador" => "xpalclavsec329291" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusion" ] 8 => array:3 [ "identificador" => "sec0025" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-09-08" "fechaAceptado" => "2013-12-31" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec329290" "palabras" => array:3 [ 0 => "Post-cardiac injury syndrome" 1 => "Cardiac rupture" 2 => "Pacemaker implantation" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec329291" "palabras" => array:3 [ 0 => "Síndrome pós-lesão cardíaca" 1 => "Rotura cardíaca" 2 => "Implantação de <span class="elsevierStyleItalic">pacemaker</span>" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Post-cardiac injury syndrome (PCIS) is an inflammatory process involving the pericardium secondary to cardiac injury. It can develop after cardiac trauma, cardiac surgery, myocardial infarction, and, rarely, after certain intravascular procedures. We report a rare case of an iatrogenic cardiac rupture followed by PCIS with delayed inflammatory pericardial effusion after pacemaker implantation. A comprehensive literature review on this topic is provided.</p>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A síndrome pós-lesão cardíaca (SPLC) corresponde a um processo inflamatório envolvendo o pericárdio, secundário à lesão cardíaca. Pode desenvolver-se após traumatismo cardíaco, cirurgia cardíaca, enfarte agudo do miocárdio, e, raramente, após alguns procedimentos intravasculares. Os autores apresentam o caso invulgar de uma rotura cardíaca iatrogénica após implantação de um <span class="elsevierStyleItalic">pacemaker</span>, seguida pelo desenvolvimento de um derrame pericárdico retardado, inflamatório, correspondendo a SPLC. A propósito do referido caso clínico, é efetuada uma revisão compreensiva da literatura acerca desta entidade.</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" => 530 "Ancho" => 1800 "Tamanyo" => 90512 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Echocardiographic subcostal views: (A) after permanent pacemaker implantation revealing a new moderate pericardial effusion (arrow); (B) at hospital discharge, after a few days of clinical surveillance with no evidence of pericardial effusion (arrow); and (C) at readmission, with a large pericardial effusion and ‘swinging heart’ (arrow).</p>" ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">ADA: adenosine deaminase; LDH: lactate dehydrogenase.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Appearance \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Light yellow \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nucleated cell count, 10<span class="elsevierStyleSup">9</span>/l \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Neutrophils, % \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">66 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lymphocytes, % \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">26 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total protein, g/dl \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">49.20 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LDH, U/l \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">781 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ADA, U/l \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">pH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Microbiology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sterile \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab518338.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Analysis of pericardial fluid.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Post-cardiac injury syndrome following transvenous pacemaker insertion: a case report and review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "C. Cevik" 1 => "T. Wilborn" 2 => "R. Corona" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.hlc.2009.04.001" "Revista" => array:6 [ "tituloSerie" => "Heart Lung Circ" "fecha" => "2009" "volumen" => "18" "paginaInicial" => "379" "paginaFinal" => "383" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19647485" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Post-cardiac injury syndromes. An emerging cause of pericardial diseases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M. Imazio" 1 => "B.D. Hoit" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ijcard.2011.06.042" "Revista" => array:3 [ "tituloSerie" => "Int J Cardiol" "fecha" => "2012" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21757243" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Incidence and clinical characteristics of postcardiac injury syndrome complicating cardiac perforation caused by radiofrequency catheter ablation for cardiac arrhythmias" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "Y. Liu" 1 => "C. Wang" 2 => "R. Zhao" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ijcard.2011.06.042" "Revista" => array:3 [ "tituloSerie" => "Int J Cardiol" "fecha" => "2013" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21757243" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The pleuropulmonary manifestations of the postcardiac injury syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:2 [ 0 => "T.J. Stelzner" 1 => "T.E. King Jr." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Chest." "fecha" => "1983" "volumen" => "84" "paginaInicial" => "383" "paginaFinal" => "387" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/6617272" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0090429512007935" "estado" => "S300" "issn" => "00904295" ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Recurrent delayed pericarditis after pacemaker implantation: a post-pericardiotomy-like syndrome?" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "J. Vinit" 1 => "P. Sagnol" 2 => "P. Buttard" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "La Rev Med Int" "fecha" => "2007" "volumen" => "28" "paginaInicial" => "137" "paginaFinal" => "140" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Immunological analysis of pleural fluid in post-cardiac injury syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "R. Shrivastava" 1 => "S. Venkatesh" 2 => "B.B. Pavlovich" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Postgrad Med J" "fecha" => "2002" "volumen" => "78" "paginaInicial" => "362" "paginaFinal" => "363" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12151693" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Postcardiac injury syndrome. An immunologic pleural fluid analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S. Kim" 1 => "S.A. Sahn" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "1996" "volumen" => "109" "paginaInicial" => "570" "paginaFinal" => "572" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8620742" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Postcardiac injury syndrome following transvenous pacer or defibrillator insertion: CT imaging and review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "B. Wolk" 1 => "E. Dandes" 2 => "F. Martinez" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Curr Probl Diag Radiol" "fecha" => "2013" "volumen" => "42" "paginaInicial" => "141" "paginaFinal" => "148" "itemHostRev" => array:3 [ "pii" => "S0015028207031731" "estado" => "S300" "issn" => "00150282" ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/08702551/0000003300000005/v1_201406210043/S0870255114001061/v1_201406210043/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/08702551/0000003300000005/v1_201406210043/S0870255114001061/v1_201406210043/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255114001061?idApp=UINPBA00004E" ]
| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 8 | 7 | 15 |
| 2024 Outubro | 55 | 28 | 83 |
| 2024 Setembro | 60 | 24 | 84 |
| 2024 Agosto | 61 | 27 | 88 |
| 2024 Julho | 44 | 35 | 79 |
| 2024 Junho | 43 | 19 | 62 |
| 2024 Maio | 41 | 15 | 56 |
| 2024 Abril | 39 | 24 | 63 |
| 2024 Maro | 42 | 19 | 61 |
| 2024 Fevereiro | 46 | 19 | 65 |
| 2024 Janeiro | 39 | 28 | 67 |
| 2023 Dezembro | 43 | 23 | 66 |
| 2023 Novembro | 45 | 16 | 61 |
| 2023 Outubro | 30 | 15 | 45 |
| 2023 Setembro | 44 | 21 | 65 |
| 2023 Agosto | 37 | 17 | 54 |
| 2023 Julho | 39 | 8 | 47 |
| 2023 Junho | 37 | 12 | 49 |
| 2023 Maio | 58 | 19 | 77 |
| 2023 Abril | 45 | 3 | 48 |
| 2023 Maro | 45 | 19 | 64 |
| 2023 Fevereiro | 36 | 16 | 52 |
| 2023 Janeiro | 19 | 7 | 26 |
| 2022 Dezembro | 45 | 12 | 57 |
| 2022 Novembro | 57 | 19 | 76 |
| 2022 Outubro | 37 | 20 | 57 |
| 2022 Setembro | 61 | 23 | 84 |
| 2022 Agosto | 35 | 31 | 66 |
| 2022 Julho | 49 | 34 | 83 |
| 2022 Junho | 24 | 21 | 45 |
| 2022 Maio | 36 | 30 | 66 |
| 2022 Abril | 43 | 28 | 71 |
| 2022 Maro | 33 | 30 | 63 |
| 2022 Fevereiro | 30 | 25 | 55 |
| 2022 Janeiro | 69 | 19 | 88 |
| 2021 Dezembro | 44 | 29 | 73 |
| 2021 Novembro | 50 | 36 | 86 |
| 2021 Outubro | 67 | 41 | 108 |
| 2021 Setembro | 45 | 31 | 76 |
| 2021 Agosto | 41 | 27 | 68 |
| 2021 Julho | 36 | 22 | 58 |
| 2021 Junho | 33 | 25 | 58 |
| 2021 Maio | 38 | 25 | 63 |
| 2021 Abril | 44 | 32 | 76 |
| 2021 Maro | 64 | 16 | 80 |
| 2021 Fevereiro | 71 | 9 | 80 |
| 2021 Janeiro | 38 | 7 | 45 |
| 2020 Dezembro | 48 | 5 | 53 |
| 2020 Novembro | 69 | 17 | 86 |
| 2020 Outubro | 25 | 8 | 33 |
| 2020 Setembro | 82 | 13 | 95 |
| 2020 Agosto | 42 | 7 | 49 |
| 2020 Julho | 51 | 6 | 57 |
| 2020 Junho | 50 | 6 | 56 |
| 2020 Maio | 58 | 2 | 60 |
| 2020 Abril | 28 | 8 | 36 |
| 2020 Maro | 56 | 11 | 67 |
| 2020 Fevereiro | 43 | 16 | 59 |
| 2020 Janeiro | 37 | 4 | 41 |
| 2019 Dezembro | 45 | 8 | 53 |
| 2019 Novembro | 23 | 6 | 29 |
| 2019 Outubro | 63 | 7 | 70 |
| 2019 Setembro | 15 | 9 | 24 |
| 2019 Agosto | 26 | 9 | 35 |
| 2019 Julho | 57 | 15 | 72 |
| 2019 Junho | 34 | 4 | 38 |
| 2019 Maio | 61 | 6 | 67 |
| 2019 Abril | 26 | 14 | 40 |
| 2019 Maro | 35 | 16 | 51 |
| 2019 Fevereiro | 48 | 11 | 59 |
| 2019 Janeiro | 31 | 5 | 36 |
| 2018 Dezembro | 50 | 15 | 65 |
| 2018 Novembro | 82 | 9 | 91 |
| 2018 Outubro | 124 | 9 | 133 |
| 2018 Setembro | 55 | 13 | 68 |
| 2018 Agosto | 48 | 10 | 58 |
| 2018 Julho | 28 | 9 | 37 |
| 2018 Junho | 61 | 8 | 69 |
| 2018 Maio | 47 | 12 | 59 |
| 2018 Abril | 52 | 4 | 56 |
| 2018 Maro | 52 | 6 | 58 |
| 2018 Fevereiro | 47 | 4 | 51 |
| 2018 Janeiro | 29 | 6 | 35 |
| 2017 Dezembro | 77 | 8 | 85 |
| 2017 Novembro | 49 | 9 | 58 |
| 2017 Outubro | 36 | 9 | 45 |
| 2017 Setembro | 43 | 10 | 53 |
| 2017 Agosto | 44 | 11 | 55 |
| 2017 Julho | 23 | 9 | 32 |
| 2017 Junho | 53 | 8 | 61 |
| 2017 Maio | 29 | 6 | 35 |
| 2017 Abril | 43 | 9 | 52 |
| 2017 Maro | 26 | 47 | 73 |
| 2017 Fevereiro | 23 | 5 | 28 |
| 2017 Janeiro | 31 | 3 | 34 |
| 2016 Dezembro | 28 | 3 | 31 |
| 2016 Novembro | 33 | 4 | 37 |
| 2016 Outubro | 69 | 4 | 73 |
| 2016 Setembro | 52 | 5 | 57 |
| 2016 Agosto | 25 | 6 | 31 |
| 2016 Julho | 17 | 7 | 24 |
| 2016 Junho | 4 | 6 | 10 |
| 2016 Maio | 18 | 0 | 18 |
| 2016 Abril | 33 | 1 | 34 |
| 2016 Maro | 59 | 7 | 66 |
| 2016 Fevereiro | 56 | 14 | 70 |
| 2016 Janeiro | 54 | 10 | 64 |
| 2015 Dezembro | 58 | 6 | 64 |
| 2015 Novembro | 61 | 11 | 72 |
| 2015 Outubro | 70 | 5 | 75 |
| 2015 Setembro | 60 | 18 | 78 |
| 2015 Agosto | 63 | 8 | 71 |
| 2015 Julho | 49 | 10 | 59 |
| 2015 Junho | 57 | 4 | 61 |
| 2015 Maio | 69 | 8 | 77 |
| 2015 Abril | 36 | 10 | 46 |
| 2015 Maro | 31 | 5 | 36 |
| 2015 Fevereiro | 36 | 8 | 44 |
| 2015 Janeiro | 41 | 12 | 53 |
| 2014 Dezembro | 49 | 17 | 66 |
| 2014 Novembro | 51 | 15 | 66 |
| 2014 Outubro | 66 | 9 | 75 |
| 2014 Setembro | 54 | 12 | 66 |
| 2014 Agosto | 43 | 15 | 58 |
| 2014 Julho | 73 | 35 | 108 |
| 2014 Junho | 18 | 14 | 32 |
Mostrar tudo
