Case report
Percutaneous balloon mitral valvuloplasty and closure of the left atrial appendage: Synergy of two procedures in one percutaneous intervention
Valvuloplastia mitral percutânea por balão e encerramento do apêndice auricular esquerdo. Sinergia de dois procedimentos numa única intervenção percutânea
Lido
7735
Vezesque se leu este artigo
1990
Total PDF
5745
Total HTML
Compartilhar estatísticas
array:25 [ "pii" => "S087025511630186X" "issn" => "08702551" "doi" => "10.1016/j.repc.2016.01.008" "estado" => "S300" "fechaPublicacion" => "2016-11-01" "aid" => "875" "copyright" => "Sociedade Portuguesa de Cardiologia" "copyrightAnyo" => "2016" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Rev Port Cardiol. 2016;35:617.e1-7" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 3429 "formatos" => array:3 [ "EPUB" => 202 "HTML" => 2694 "PDF" => 533 ] ] "Traduccion" => array:1 [ "en" => array:20 [ "pii" => "S2174204916302069" "issn" => "21742049" "doi" => "10.1016/j.repce.2016.10.008" "estado" => "S300" "fechaPublicacion" => "2016-11-01" "aid" => "875" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Rev Port Cardiol. 2016;35:617.e1-7" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 3064 "formatos" => array:3 [ "EPUB" => 199 "HTML" => 2474 "PDF" => 391 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Percutaneous balloon mitral valvuloplasty and closure of the left atrial appendage: Synergy of two procedures in one percutaneous intervention" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "617.e1" "paginaFinal" => "617.e7" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Valvuloplastia mitral percutânea por balão e encerramento do apêndice auricular esquerdo. Sinergia de dois procedimentos numa única intervenção percutânea" ] ] "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" => "fig0040" "etiqueta" => "Figure 8" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr8.jpeg" "Alto" => 676 "Ancho" => 2050 "Tamanyo" => 228592 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Fluoroscopic images of release of the Amplatzer Cardiac Plug by the left atrial appendage.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Daniele Gemma, Raúl Moreno Gómez, Jaime Fernández de Bobadilla, Guillermo Galeote García, Teresa López Fernandez, Jose R. López-Mínguez, José L. López-Sendón" "autores" => array:7 [ 0 => array:2 [ "nombre" => "Daniele" "apellidos" => "Gemma" ] 1 => array:2 [ "nombre" => "Raúl" "apellidos" => "Moreno Gómez" ] 2 => array:2 [ "nombre" => "Jaime" "apellidos" => "Fernández de Bobadilla" ] 3 => array:2 [ "nombre" => "Guillermo" "apellidos" => "Galeote García" ] 4 => array:2 [ "nombre" => "Teresa" "apellidos" => "López Fernandez" ] 5 => array:2 [ "nombre" => "Jose R." "apellidos" => "López-Mínguez" ] 6 => array:2 [ "nombre" => "José L." "apellidos" => "López-Sendón" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S087025511630186X" "doi" => "10.1016/j.repc.2016.01.008" "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/S087025511630186X?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204916302069?idApp=UINPBA00004E" "url" => "/21742049/0000003500000011/v1_201611160155/S2174204916302069/v1_201611160155/en/main.assets" ] ] "itemSiguiente" => array:20 [ "pii" => "S0870255116301482" "issn" => "08702551" "doi" => "10.1016/j.repc.2016.03.008" "estado" => "S300" "fechaPublicacion" => "2016-11-01" "aid" => "857" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Rev Port Cardiol. 2016;35:619.e1-5" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 8413 "formatos" => array:3 [ "EPUB" => 240 "HTML" => 7279 "PDF" => 894 ] ] "pt" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Caso Clínico</span>" "titulo" => "Hipersensibilidade à aspirina e coronariografia urgente: desafio terapêutico" "tienePdf" => "pt" "tieneTextoCompleto" => "pt" "tieneResumen" => array:2 [ 0 => "pt" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "619.e1" "paginaFinal" => "619.e5" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Hypersensitivity to aspirin and urgent percutaneous coronary intervention: A therapeutic challenge" ] ] "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" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2021 "Ancho" => 2333 "Tamanyo" => 247572 ] ] "descripcion" => array:1 [ "pt" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Algoritmo de decisão: doentes com DAC e hipersensibilidade à AAS (adaptado do <span class="elsevierStyleItalic">Aspirin Sensitivity: implications for patients with coronary artery disease</span>; JAMA; 2004; Vol 292; No.24).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Tatiana Duarte, Sara Gonçalves, Catarina Sá, Rita Marinheiro, Rita Rodrigues, Filipe Seixo, Elza Tomas, Rui Caria" "autores" => array:8 [ 0 => array:2 [ "nombre" => "Tatiana" "apellidos" => "Duarte" ] 1 => array:2 [ "nombre" => "Sara" "apellidos" => "Gonçalves" ] 2 => array:2 [ "nombre" => "Catarina" "apellidos" => "Sá" ] 3 => array:2 [ "nombre" => "Rita" "apellidos" => "Marinheiro" ] 4 => array:2 [ "nombre" => "Rita" "apellidos" => "Rodrigues" ] 5 => array:2 [ "nombre" => "Filipe" "apellidos" => "Seixo" ] 6 => array:2 [ "nombre" => "Elza" "apellidos" => "Tomas" ] 7 => array:2 [ "nombre" => "Rui" "apellidos" => "Caria" ] ] ] ] ] "idiomaDefecto" => "pt" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2174204916301532" "doi" => "10.1016/j.repce.2016.03.010" "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/S2174204916301532?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255116301482?idApp=UINPBA00004E" "url" => "/08702551/0000003500000011/v1_201610280519/S0870255116301482/v1_201610280519/pt/main.assets" ] "itemAnterior" => array:20 [ "pii" => "S0870255116301895" "issn" => "08702551" "doi" => "10.1016/j.repc.2016.06.007" "estado" => "S300" "fechaPublicacion" => "2016-11-01" "aid" => "878" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "ssu" "cita" => "Rev Port Cardiol. 2016;35:601-16" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 5103 "formatos" => array:3 [ "EPUB" => 208 "HTML" => 4018 "PDF" => 877 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review article</span>" "titulo" => "Type 4 cardiorenal syndrome" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "601" "paginaFinal" => "616" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Síndrome cardiorrenal tipo 4" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Adapted from Go et al.<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">29</span></a>" "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1224 "Ancho" => 3373 "Tamanyo" => 258447 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Age-standardized rates of death from any cause, cardiovascular events and hospitalization, according to estimated GFR among 1<span class="elsevierStyleHsp" style=""></span>120<span class="elsevierStyleHsp" style=""></span>295 ambulatory adults. Cardiovascular events included hospitalization for coronary artery disease, heart failure, stroke or transient ischemic attack, and peripheral arterial disease. GFR: glomerular filtration rate.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Ana Luísa Pinheiro da Silva, Manuel Joaquim Vaz da Silva" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Ana Luísa" "apellidos" => "Pinheiro da Silva" ] 1 => array:2 [ "nombre" => "Manuel Joaquim" "apellidos" => "Vaz da Silva" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2174204916302136" "doi" => "10.1016/j.repce.2016.10.015" "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/S2174204916302136?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255116301895?idApp=UINPBA00004E" "url" => "/08702551/0000003500000011/v1_201610280519/S0870255116301895/v1_201610280519/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Percutaneous balloon mitral valvuloplasty and closure of the left atrial appendage: Synergy of two procedures in one percutaneous intervention" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "617.e1" "paginaFinal" => "617.e7" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Daniele Gemma, Raúl Moreno Gómez, Jaime Fernández de Bobadilla, Guillermo Galeote García, Teresa López Fernandez, Jose R. López-Mínguez, José L. López-Sendón" "autores" => array:7 [ 0 => array:4 [ "nombre" => "Daniele" "apellidos" => "Gemma" "email" => array:1 [ 0 => "daniele.gemma@hotmail.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" => "Raúl" "apellidos" => "Moreno Gómez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Jaime" "apellidos" => "Fernández de Bobadilla" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Guillermo" "apellidos" => "Galeote García" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Teresa" "apellidos" => "López Fernandez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "Jose R." "apellidos" => "López-Mínguez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 6 => array:3 [ "nombre" => "José L." "apellidos" => "López-Sendón" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Hospital Universitario La Paz, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Hospital Infanta Cristina, Badajoz, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Valvuloplastia mitral percutânea por balão e encerramento do apêndice auricular esquerdo. Sinergia de dois procedimentos numa única intervenção percutânea" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0045" "etiqueta" => "Figure 9" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr9.jpeg" "Alto" => 662 "Ancho" => 2000 "Tamanyo" => 109283 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiographic images with three-dimensional reconstruction of the Amplatzer Cardiac Plug in follow-up.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Mitral stenosis (MS) is associated with increased thromboembolic risk, especially in individuals with atrial fibrillation (AF), a common finding in these patients.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1,2</span></a> Percutaneous mitral valvuloplasty (PMV) in patients with hemodynamically significant MS is associated with a reduction in thromboembolic risk.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> Also, percutaneous left atrial appendage (LAA) closure is an emerging procedure that may be considered in patients with AF with high thromboembolic risk and in whom chronic oral anticoagulation is contraindicated.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">4–6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We describe the case of a patient with significant MS and a history of repeated thromboembolic events in spite of oral anticoagulation with acenocoumarol who underwent both PMV and percutaneous LAA closure in the same procedure. Synergies between the two procedures are discussed.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0015" class="elsevierStylePara elsevierViewall">A 57-year-old woman with significant MS, in New York Heart Association functional class II/IV, was referred to our unit for PMV, as echocardiographic parameters were suitable (mitral area 1.1 cm<span class="elsevierStyleSup">2</span>, mild mitral regurgitation, Wilkins score 7). Interestingly, she had previously undergone PMV 12 years before.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The patient had permanent AF and was treated chronically with acenocoumarol. Despite adequate oral anticoagulation, in the last four years she had presented at least two episodes of ischemic stroke: an embolic stroke two years previously in the right middle cerebral artery territory, and an embolic stroke eight months previously in the right posterior inferior cerebellar artery which caused transtentorial herniation. After these episodes the patient presented an acceptable neurological recovery and was independent for everyday activities. One month before admission, she had presented a non-ST-segment elevation acute myocardial infarction. Coronary computed tomography showed no coronary stenosis. Coronary embolism was diagnosed as the probable cause of the ischemic event and the patient had no recurrent ischemia or other complications. Our center's heart team decided to perform PMV and percutaneous LAA closure during the same procedure.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Transesophageal echocardiography performed 24 hours prior to the procedure showed no thrombus in the left appendage but revealed the presence of high-density spontaneous contrast (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). The LAA showed a 29 mm×26 mm entry orifice (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">In the procedure, the middle portion of the interatrial septum was punctured (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>) and PMV was performed first by the usual technique with a Mullins sheath and a Brockenbrough needle and inflation of a 26 mm Inoue balloon (<a class="elsevierStyleCrossRefs" href="#fig0020">Figures 4 and 5</a>), with a good result (absence of transmitral gradient, 2.1 cm<span class="elsevierStyleSup">2</span> mitral area and no increase in the degree of valvular regurgitation). Percutaneous LAA closure was then performed. Keeping the guidewire in the same transseptal puncture, a pigtail catheter was introduced into the LAA to allow selective injections into this structure (<a class="elsevierStyleCrossRef" href="#fig0030">Figure 6</a>). A 30 mm Amplatzer Cardiac Plug (ACP) (St. Jude Medical), specific for percutaneous LAA closure, was inserted via the ACP release sheath and implanted in the left appendage. It was released successfully and without complications (<a class="elsevierStyleCrossRefs" href="#fig0035">Figures 7 and 8</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia><elsevierMultimedia ident="fig0035"></elsevierMultimedia><elsevierMultimedia ident="fig0040"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The patient was discharged on indefinite treatment with acenocoumarol, associated with aspirin (100 mg/d) for three months. After one year follow-up there have been no further embolic episodes or other complications (<a class="elsevierStyleCrossRef" href="#fig0045">Figure 9</a>).</p><elsevierMultimedia ident="fig0045"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">PMV is a common procedure in patients with significant MS, poor functional class and echocardiographic parameters suitable for the technique. The procedure also shows good results in patients who have previously undergone PMV, as in the case of our patient.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> What makes the case described interesting is the fact that the patient had presented numerous cardioembolic episodes in spite of adequate chronic oral anticoagulation, so it was decided to undertake a combined PMV and percutaneous LAA closure procedure to reduce the risk of post-PMV embolic recurrence. Since a number of the potential complications of percutaneous LAA closure are associated with transseptal puncture, also used for PMV, the risk of performing the two procedures together is probably lower than if they are done separately. There are technical considerations related to the site of the transseptal puncture, since the ideal position differs according to the type of procedure. In our case the puncture was performed in the mid portion of the septum, allowing a relatively easy procedure.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Significant MS increases pressure and alters flow in the left atrium. This is associated with an increased incidence of AF and hypercoagulability, both explaining the high rate of embolism in patients with this valvulopathy.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> PMV has been shown to reduce the incidence of systemic embolism in MS, and PMV is therefore recommended even in patients with significant asymptomatic MS and high thromboembolic risk.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> In the case presented, the therapeutic strategy adopted was intended not only to improve functional class, but also to reduce the risk of recurrent embolism by the double mechanism of improving hemodynamic parameters in the left atrium and excluding the LAA.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Percutaneous LAA closure is becoming increasingly common in patients with AF, high embolic risk and contraindications for anticoagulation, but very few data are available regarding this procedure in patients with rheumatic AF. The guidelines recommend LAA closure during surgical MS procedures, as it is associated with a significant reduction in risk of postoperative embolic events.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">7–9</span></a> Similarly, some patients undergoing PMV may also benefit from percutaneous LAA closure performed during the same operation.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Our patient was discharged under chronic oral anticoagulation, since LAA closure does not completely eliminate the risk of embolism in MS patients and she had no contraindications for this treatment. Out of 136 patients who underwent atrial appendage closure during a mitral valve operation, Almahameed et al.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> observed that thromboembolic events were more frequent in patients whose anticoagulant treatment had been stopped after 3.5 years of treatment (10% vs. 15%). The ideal anticoagulant treatment after intracavitary device implantation is unclear, suggesting the use of aspirin in our patient in the three months following the operation.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Protection of human and animal subjects</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association (Declaration of Helsinki).</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Confidentiality of data</span><p id="par0065" 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="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Right to privacy and informed consent</span><p id="par0070" 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="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres748714" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec751463" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres748715" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec751462" "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:3 [ "identificador" => "sec0020" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Right to privacy and informed consent" ] ] ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-11-07" "fechaAceptado" => "2016-01-20" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec751463" "palabras" => array:4 [ 0 => "Percutaneous left atrial appendage closure" 1 => "Percutaneous mitral valvuloplasty" 2 => "Mitral stenosis" 3 => "Atrial fibrillation" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec751462" "palabras" => array:4 [ 0 => "Encerramento percutâneo do apêndice arterial esquerdo" 1 => "Valvuloplastia mitral percutânea" 2 => "Estenose mitral" 3 => "Fibrilhação auricular" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Mitral stenosis (MS) is frequently associated with the development of atrial fibrillation (AF) as a consequence of hemodynamic and inflammatory changes in the left atrium. Both conditions predispose to thrombus formation, with frequent involvement of the left atrial appendage (LAA), and consequent increase in the incidence of systemic thromboembolic events. Percutaneous mitral valvuloplasty (PMV) reduces the risk of thromboembolism in patients with significant mitral stenosis. Percutaneous LAA closure is also associated with a reduction in thromboembolic risk in patients with AF, but there are no data regarding the use of this technique in patients with significant mitral valve disease. We report the case of a 57-year-old-woman with significant MS and permanent AF, in New York Heart Association functional class II, who despite adequate oral anticoagulation with acenocoumarol, presented several clinical episodes of systemic thromboembolism in the last four years. It was decided to perform a combined percutaneous procedure, including both PMV and percutaneous LAA closure with the Amplatzer Cardiac Plug device. No significant acute complications occurred and the patient was discharged on indefinite treatment with acenocoumarol associated with aspirin 100 mg/d for three months. After a one-year follow-up, there have been no new embolic episodes or other complications.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A estenose mitral (EM) é frequentemente associada ao desenvolvimento de fibrilhação auricular (FA) como consequência de alterações hemodinâmicas e inflamatórias na aurícula esquerda. Ambas as condições predispõem à formação de trombos, com frequente envolvimento do apêndice auricular, e consequente aumento da incidência de eventos tromboembólicos sistémicos. A valvuloplastia mitral percutânea (VMP) reduz o risco de tromboembolismo em doentes com EM significativa. O encerramento percutâneo do apêndice auricular esquerdo (PCLAA) na FA também está associado a uma redução de risco de tromboembolismo em pacientes com FA, mas não existem dados sobre a utilização desta técnica em doentes com MS. Relatamos o caso de uma mulher de 57 anos de idade com significativa EM e FA permanente, em classe funcional II, que, apesar de anticoagulação oral adequada com acenocumarol, apresentou nos últimos quatro anos vários episódios clínicos de tromboembolismo sistémico. Foi decidido realizar um procedimento percutâneo combinado de PMV e PCLAA com dispositivo <span class="elsevierStyleItalic">Amplatzer Cardiac Plug</span>. Não se verificaram complicações agudas significativas e o paciente recebeu alta com acenocumarol de forma indefinida, associado com aspirina 100 mg/d durante três meses. Depois de um ano de <span class="elsevierStyleItalic">follow-up</span>, não houve novos episódios embólicos ou outras complicações.</p></span>" ] ] "multimedia" => array:9 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 601 "Ancho" => 1734 "Tamanyo" => 125215 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiographic images of the stenotic mitral valve and the thrombus-free left atrial appendage with spontaneous inner contrast.</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" => 1511 "Ancho" => 1501 "Tamanyo" => 143584 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiographic measurement of the entry orifice and length of the left atrial appendage.</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" => 746 "Ancho" => 1500 "Tamanyo" => 96440 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiographic image of transseptal puncture.</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" => 1262 "Ancho" => 1700 "Tamanyo" => 145485 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiographic image of percutaneous balloon mitral valvuloplasty.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 950 "Ancho" => 950 "Tamanyo" => 145313 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Fluoroscopic image of percutaneous balloon mitral valvuloplasty.</p>" ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 837 "Ancho" => 1700 "Tamanyo" => 264521 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Fluoroscopic image of selective contrast injection in the left atrial appendage.</p>" ] ] 6 => array:7 [ "identificador" => "fig0035" "etiqueta" => "Figure 7" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr7.jpeg" "Alto" => 1349 "Ancho" => 1710 "Tamanyo" => 125987 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiographic three-dimensional reconstruction of inflation and release of the Amplatzer Cardiac Plug by the left atrial appendage.</p>" ] ] 7 => array:7 [ "identificador" => "fig0040" "etiqueta" => "Figure 8" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr8.jpeg" "Alto" => 676 "Ancho" => 2050 "Tamanyo" => 223798 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Fluoroscopic images of release of the Amplatzer Cardiac Plug by the left atrial appendage.</p>" ] ] 8 => array:7 [ "identificador" => "fig0045" "etiqueta" => "Figure 9" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr9.jpeg" "Alto" => 662 "Ancho" => 2000 "Tamanyo" => 109283 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiographic images with three-dimensional reconstruction of the Amplatzer Cardiac Plug in follow-up.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pathomorphological aspects, aetiology and natural history of acquired mitral valve stenosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "D. Horstkotte" 1 => "R. Niehues" 2 => "B.E. Strauer" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Eur Heart J" "fecha" => "1991" "volumen" => "12" "numero" => "Suppl B" "paginaInicial" => "55" "paginaFinal" => "60" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1936027" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0055" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "R.O. Bonow" 1 => "B.A. Carabello" 2 => "K. Chatterjee" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/CIRCULATIONAHA.108.190748" "Revista" => array:5 [ "tituloSerie" => "Circulation" "fecha" => "2008" "volumen" => "118" "paginaInicial" => "e523" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18820172" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0060" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Predictors of systemic embolism in patients with mitral stenosis. A prospective study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "C.W. Chiang" 1 => "S.K. Lo" 2 => "Y.S. Ko" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Ann Intern Med" "fecha" => "1998" "volumen" => "128" "paginaInicial" => "885" "paginaFinal" => "889" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9634425" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0065" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Percutaneous left atrial appendage closure for stroke prophylaxis in patients with atrial fibrillation: 2.3-year follow-up of the PROTECT AF (Watchman Left Atrial Appendage System for Embolic Protection in Patients with Atrial Fibrillation) trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "V.Y. Reddy" 1 => "S.K. Doshi" 2 => "H. Sievert" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/CIRCULATIONAHA.112.114389" "Revista" => array:5 [ "tituloSerie" => "Circulation" "fecha" => "2013" "volumen" => "127" "paginaInicial" => "720" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23325525" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0070" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Left atrial appendage closure with the Watchman device in patients with a contraindication for oral anticoagulation: the ASAP study (ASA Plavix Feasibility Study With Watchman Left Atrial Appendage Closure Technology)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "V.Y. Reddy" 1 => "S. Möbius-Winkler" 2 => "M.A. Miller" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jacc.2013.03.035" "Revista" => array:5 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "2013" "volumen" => "61" "paginaInicial" => "2551" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23583249" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0075" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Percutaneous left atrial appendage closure with the AMPLATZER cardiac plug device in patients with nonvalvular atrial fibrillation and contraindications to anticoagulation therapy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M. Urena" 1 => "J. Rodés-Cabau" 2 => "X. Freixa" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jacc.2013.02.089" "Revista" => array:5 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "2013" "volumen" => "62" "paginaInicial" => "96" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23665098" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0080" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J.L. Blackshear" 1 => "J.A. Odell" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/0003-4975(95)00887-X" "Revista" => array:6 [ "tituloSerie" => "Ann Thorac Surg" "fecha" => "1996" "volumen" => "61" "paginaInicial" => "755" "paginaFinal" => "759" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8572814" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0085" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Left atrial appendage exclusion and the risk of thromboembolic events following mitral valve surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "S. Almahameed" 1 => "M. Khan" 2 => "R. Zuzek" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1540-8167.2006.00755.x" "Revista" => array:6 [ "tituloSerie" => "J Cardiovasc Electrophysiol" "fecha" => "2007" "volumen" => "18" "paginaInicial" => "364" "paginaFinal" => "366" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17286567" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0090" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Role of left atrial appendage obliteration in stroke reduction in patients with mitral valve prosthesis: a transesophageal echocardiographic study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M.A. García-Fernández" 1 => "E. Pérez-David" 2 => "J. Quiles" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "2003" "volumen" => "42" "paginaInicial" => "1253" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14522491" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/08702551/0000003500000011/v1_201610280519/S087025511630186X/v1_201610280519/en/main.assets" "Apartado" => array:4 [ "identificador" => "29263" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Casos Clínicos" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/08702551/0000003500000011/v1_201610280519/S087025511630186X/v1_201610280519/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S087025511630186X?idApp=UINPBA00004E" ]
| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 12 | 6 | 18 |
| 2024 Outubro | 55 | 36 | 91 |
| 2024 Setembro | 69 | 26 | 95 |
| 2024 Agosto | 51 | 31 | 82 |
| 2024 Julho | 48 | 33 | 81 |
| 2024 Junho | 42 | 55 | 97 |
| 2024 Maio | 50 | 22 | 72 |
| 2024 Abril | 58 | 37 | 95 |
| 2024 Maro | 41 | 24 | 65 |
| 2024 Fevereiro | 57 | 37 | 94 |
| 2024 Janeiro | 46 | 37 | 83 |
| 2023 Dezembro | 43 | 24 | 67 |
| 2023 Novembro | 59 | 19 | 78 |
| 2023 Outubro | 39 | 15 | 54 |
| 2023 Setembro | 33 | 20 | 53 |
| 2023 Agosto | 47 | 22 | 69 |
| 2023 Julho | 62 | 8 | 70 |
| 2023 Junho | 46 | 15 | 61 |
| 2023 Maio | 75 | 26 | 101 |
| 2023 Abril | 60 | 7 | 67 |
| 2023 Maro | 68 | 20 | 88 |
| 2023 Fevereiro | 64 | 18 | 82 |
| 2023 Janeiro | 42 | 12 | 54 |
| 2022 Dezembro | 65 | 29 | 94 |
| 2022 Novembro | 65 | 23 | 88 |
| 2022 Outubro | 49 | 16 | 65 |
| 2022 Setembro | 57 | 36 | 93 |
| 2022 Agosto | 51 | 30 | 81 |
| 2022 Julho | 59 | 43 | 102 |
| 2022 Junho | 48 | 23 | 71 |
| 2022 Maio | 47 | 40 | 87 |
| 2022 Abril | 69 | 27 | 96 |
| 2022 Maro | 39 | 37 | 76 |
| 2022 Fevereiro | 56 | 25 | 81 |
| 2022 Janeiro | 85 | 23 | 108 |
| 2021 Dezembro | 47 | 36 | 83 |
| 2021 Novembro | 63 | 49 | 112 |
| 2021 Outubro | 59 | 51 | 110 |
| 2021 Setembro | 42 | 25 | 67 |
| 2021 Agosto | 68 | 33 | 101 |
| 2021 Julho | 32 | 26 | 58 |
| 2021 Junho | 47 | 30 | 77 |
| 2021 Maio | 57 | 39 | 96 |
| 2021 Abril | 61 | 38 | 99 |
| 2021 Maro | 77 | 25 | 102 |
| 2021 Fevereiro | 63 | 20 | 83 |
| 2021 Janeiro | 41 | 13 | 54 |
| 2020 Dezembro | 38 | 15 | 53 |
| 2020 Novembro | 38 | 31 | 69 |
| 2020 Outubro | 44 | 25 | 69 |
| 2020 Setembro | 79 | 22 | 101 |
| 2020 Agosto | 37 | 10 | 47 |
| 2020 Julho | 72 | 14 | 86 |
| 2020 Junho | 65 | 13 | 78 |
| 2020 Maio | 48 | 10 | 58 |
| 2020 Abril | 51 | 14 | 65 |
| 2020 Maro | 47 | 11 | 58 |
| 2020 Fevereiro | 149 | 22 | 171 |
| 2020 Janeiro | 37 | 5 | 42 |
| 2019 Dezembro | 55 | 7 | 62 |
| 2019 Novembro | 68 | 9 | 77 |
| 2019 Outubro | 51 | 6 | 57 |
| 2019 Setembro | 93 | 5 | 98 |
| 2019 Agosto | 47 | 9 | 56 |
| 2019 Julho | 61 | 8 | 69 |
| 2019 Junho | 57 | 13 | 70 |
| 2019 Maio | 62 | 14 | 76 |
| 2019 Abril | 48 | 20 | 68 |
| 2019 Maro | 100 | 7 | 107 |
| 2019 Fevereiro | 125 | 12 | 137 |
| 2019 Janeiro | 93 | 10 | 103 |
| 2018 Dezembro | 77 | 14 | 91 |
| 2018 Novembro | 146 | 12 | 158 |
| 2018 Outubro | 197 | 14 | 211 |
| 2018 Setembro | 59 | 13 | 72 |
| 2018 Agosto | 33 | 9 | 42 |
| 2018 Julho | 30 | 10 | 40 |
| 2018 Junho | 48 | 8 | 56 |
| 2018 Maio | 41 | 12 | 53 |
| 2018 Abril | 68 | 11 | 79 |
| 2018 Maro | 84 | 11 | 95 |
| 2018 Fevereiro | 40 | 4 | 44 |
| 2018 Janeiro | 77 | 7 | 84 |
| 2017 Dezembro | 102 | 13 | 115 |
| 2017 Novembro | 61 | 6 | 67 |
| 2017 Outubro | 43 | 11 | 54 |
| 2017 Setembro | 37 | 9 | 46 |
| 2017 Agosto | 42 | 12 | 54 |
| 2017 Julho | 40 | 21 | 61 |
| 2017 Junho | 38 | 11 | 49 |
| 2017 Maio | 51 | 11 | 62 |
| 2017 Abril | 41 | 8 | 49 |
| 2017 Maro | 48 | 14 | 62 |
| 2017 Fevereiro | 34 | 25 | 59 |
| 2017 Janeiro | 39 | 11 | 50 |
| 2016 Dezembro | 73 | 23 | 96 |
| 2016 Novembro | 86 | 54 | 140 |
| 2016 Outubro | 31 | 34 | 65 |
| 2016 Setembro | 0 | 3 | 3 |
Mostrar tudo
