Case report
Mitral valve aneurysm: A serious complication of aortic valve endocarditis
Aneurisma da válvula mitral: uma complicação grave da endocardite valvular aórtica
Maria João Sousa
, Vasco Alves, Sofia Cabral, Nuno Antunes, Luís Sousa Pereira, Filomena Oliveira, João Silveira, Severo Torres
Autor para correspondência
Serviço de Cardiologia, Centro Hospitalar do Porto, Porto, Portugal
Lido
10012
Vezesque se leu este artigo
2112
Total PDF
7900
Total HTML
Compartilhar estatísticas
array:25 [ "pii" => "S0870255116301871" "issn" => "08702551" "doi" => "10.1016/j.repc.2016.02.006" "estado" => "S300" "fechaPublicacion" => "2016-11-01" "aid" => "876" "copyright" => "Sociedade Portuguesa de Cardiologia" "copyrightAnyo" => "2016" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Rev Port Cardiol. 2016;35:621.e1-5" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 4667 "formatos" => array:3 [ "EPUB" => 221 "HTML" => 3834 "PDF" => 612 ] ] "Traduccion" => array:1 [ "en" => array:20 [ "pii" => "S2174204916302057" "issn" => "21742049" "doi" => "10.1016/j.repce.2016.10.007" "estado" => "S300" "fechaPublicacion" => "2016-11-01" "aid" => "876" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Rev Port Cardiol. 2016;35:621.e1-5" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 3319 "formatos" => array:3 [ "EPUB" => 202 "HTML" => 2565 "PDF" => 552 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Mitral valve aneurysm: A serious complication of aortic valve endocarditis" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "621.e1" "paginaFinal" => "621.e5" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Aneurisma da válvula mitral: uma complicação grave da endocardite valvular aórtica" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 576 "Ancho" => 1614 "Tamanyo" => 136921 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiogram (3-chamber view). (A) Ruptured aneurysm of the anterior mitral valve leaflet. The long arrow points to the entry site and the small arrow points to the exit site of the aneurysm; (B) color Doppler image showing two mitral regurgitation jets: a small jet through the leaflet coaptation point (small arrow) and a much more significant one through the aneurysm (long arrow).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Maria João Sousa, Vasco Alves, Sofia Cabral, Nuno Antunes, Luís Sousa Pereira, Filomena Oliveira, João Silveira, Severo Torres" "autores" => array:8 [ 0 => array:2 [ "nombre" => "Maria João" "apellidos" => "Sousa" ] 1 => array:2 [ "nombre" => "Vasco" "apellidos" => "Alves" ] 2 => array:2 [ "nombre" => "Sofia" "apellidos" => "Cabral" ] 3 => array:2 [ "nombre" => "Nuno" "apellidos" => "Antunes" ] 4 => array:2 [ "nombre" => "Luís Sousa" "apellidos" => "Pereira" ] 5 => array:2 [ "nombre" => "Filomena" "apellidos" => "Oliveira" ] 6 => array:2 [ "nombre" => "João" "apellidos" => "Silveira" ] 7 => array:2 [ "nombre" => "Severo" "apellidos" => "Torres" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0870255116301871" "doi" => "10.1016/j.repc.2016.02.006" "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/S0870255116301871?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204916302057?idApp=UINPBA00004E" "url" => "/21742049/0000003500000011/v1_201611160155/S2174204916302057/v1_201611160155/en/main.assets" ] ] "itemSiguiente" => array:20 [ "pii" => "S0870255116301913" "issn" => "08702551" "doi" => "10.1016/j.repc.2015.12.012" "estado" => "S300" "fechaPublicacion" => "2016-11-01" "aid" => "880" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "sco" "cita" => "Rev Port Cardiol. 2016;35:623-5" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2526 "formatos" => array:3 [ "EPUB" => 192 "HTML" => 1772 "PDF" => 562 ] ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Image in Cardiology</span>" "titulo" => "Bioresorbable scaffold adjustment in an ostial lesion with the Szabo technique" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "623" "paginaFinal" => "625" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Ajuste de plataforma biorreabsorvível em lesão ostial pela técnica de Szabo" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 849 "Ancho" => 1600 "Tamanyo" => 155951 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Intracoronary optical coherence tomography revealing optimal strut apposition (A) and the small anchoring strut (white arrow) floating in the circumflex ostium; (B) two-dimensional view from the left anterior descending (LAD); (C) three-dimensional reconstruction, view from LAD.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Carlos Galvão Braga, Raymundo Ocaranza-Sánchez, Santiago Gestal, Ramiro Trillo, José Ramón González-Juanatey" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Carlos" "apellidos" => "Galvão Braga" ] 1 => array:2 [ "nombre" => "Raymundo" "apellidos" => "Ocaranza-Sánchez" ] 2 => array:2 [ "nombre" => "Santiago" "apellidos" => "Gestal" ] 3 => array:2 [ "nombre" => "Ramiro" "apellidos" => "Trillo" ] 4 => array:2 [ "nombre" => "José Ramón" "apellidos" => "González-Juanatey" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2174204916302112" "doi" => "10.1016/j.repce.2016.10.013" "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/S2174204916302112?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255116301913?idApp=UINPBA00004E" "url" => "/08702551/0000003500000011/v1_201610280519/S0870255116301913/v1_201610280519/en/main.assets" ] "itemAnterior" => 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" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Mitral valve aneurysm: A serious complication of aortic valve endocarditis" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "621.e1" "paginaFinal" => "621.e5" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Maria João Sousa, Vasco Alves, Sofia Cabral, Nuno Antunes, Luís Sousa Pereira, Filomena Oliveira, João Silveira, Severo Torres" "autores" => array:8 [ 0 => array:4 [ "nombre" => "Maria João" "apellidos" => "Sousa" "email" => array:1 [ 0 => "maria.sousa.101@sapo.pt" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Vasco" "apellidos" => "Alves" ] 2 => array:2 [ "nombre" => "Sofia" "apellidos" => "Cabral" ] 3 => array:2 [ "nombre" => "Nuno" "apellidos" => "Antunes" ] 4 => array:2 [ "nombre" => "Luís Sousa" "apellidos" => "Pereira" ] 5 => array:2 [ "nombre" => "Filomena" "apellidos" => "Oliveira" ] 6 => array:2 [ "nombre" => "João" "apellidos" => "Silveira" ] 7 => array:2 [ "nombre" => "Severo" "apellidos" => "Torres" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Serviço de Cardiologia, Centro Hospitalar do Porto, Porto, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Aneurisma da válvula mitral: uma complicação grave da endocardite valvular aórtica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 885 "Ancho" => 2501 "Tamanyo" => 207899 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Transthoracic echocardiogram (parasternal long-axis view). (A) Saccular bulge on the atrial side of the anterior mitral valve leaflet (small arrow) and a vegetation on the aortic valve prolapsing into the left ventricular outflow tract, in close contact with the anterior mitral valve leaflet (long arrow); (B) significant mitral regurgitation (color flow Doppler).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Case report</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 70-year-old male patient with type 2 diabetes mellitus and chronic hepatitis C virus infection presented to the emergency department with a four-month history of intermittent fever, night sweats, weight loss and progressive dyspnea. There was no past history of cardiovascular disease or illicit drug abuse. On physical examination, he was febrile (38.1<span class="elsevierStyleHsp" style=""></span>°C), his pulse was 124 bpm, blood pressure was 114/73 mmHg and he had signs of left heart failure. Cardiac auscultation disclosed a grade 3/6 pansystolic murmur at the apex. Blood cultures were positive for <span class="elsevierStyleItalic">Streptococcus viridans</span>.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Transthoracic echocardiography (TTE) showed multiple aortic valve vegetations (some prolapsing into the left ventricular outflow tract), mild aortic regurgitation and a large saccular bulge originating from the anterior mitral valve leaflet and protruding into the left atrium with severe mitral regurgitation (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>); left ventricular systolic function was normal. With transesophageal echocardiography (TEE) it became clear that the saccular bulging on the mitral valve was an anterior mitral valve leaflet aneurysm with two rupture sites (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>). Color flow Doppler showed two regurgitant jets: one through the coaptation margin of the mitral valve leaflets and the other across the perforated aneurysm (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>). There was no evidence of either aortic ring abscess formation or extension along the mitral-aortic intervalvular fibrosa.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Antibiotic therapy was started with vancomycin plus gentamicin (due to penicillin allergy) for infective endocarditis (IE). After clinical stabilization, he was referred for urgent cardiac surgery. Given his clinical stability, surgery was delayed for four more days of antibiotic therapy. The patient died suddenly one day before scheduled surgical intervention.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">Mitral valve aneurysms (MVAs) are uncommon but potentially serious complications, occurring most frequently in association with aortic valve endocarditis.<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">1–4</span></a> The first case was reported by Morand in 1729.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">5</span></a> In 1970, Gonzalez-Lavin et al.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">6</span></a> reported secondary involvement of the mitral valve with leaflet aneurysm in two (3.4%) patients out of 58 who underwent aortic valve surgery for IE. Similar results were reported in 1992 by Karalis et al.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">7</span></a> in a group of 55 patients with aortic valve endocarditis evaluated by TEE. More recent reports present a very low incidence, around 0.2-0.29% of patients who undergo TEE.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">2,4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Although most frequently associated with IE, other non-infectious etiologies have been reported including congenital cardiac structural defects, extreme forms of mitral valve prolapse, Libman-Sacks endocarditis and connective tissue disorders such as Marfan syndrome, Ehlers-Danlos syndrome, pseudoxanthoma elasticum and osteogenesis imperfecta.<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">4,9–13</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Because MVA is rare in the absence of IE, an infectious etiology will be at least partly responsible for leaflet degeneration. Proposed mechanisms for the development of MVA in the setting of aortic valve endocarditis include direct extension of the infection through the mitral-aortic intervalvular fibrosa to the anterior mitral valve leaflet with abscess formation and subsequent drainage, seeding of the anterior mitral valve leaflet by the aortic regurgitant jet (‘jet lesion’),<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">1,3,8,14–16</span></a> or through direct contact with an aortic vegetation prolapsing into the left ventricular outflow tract (‘kissing vegetation’), especially if the vegetation exceeds 6 mm in size.<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">17</span></a> These processes are thought to cause localized inflammation, weakness, dissection, and subsequent expansion of the valvular tissue, which in turn protrudes toward the left atrium due to ventricular systolic pressure, leading to aneurysm formation.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">2,18–21</span></a> In our case, because aortic regurgitation was only mild, we believe that the most likely mechanism for aneurysm development was previous abscess formation (secondary to direct extension of infection from the aortic valve or a prolapsing aortic vegetation) followed by rupture and drainage.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The diagnosis may be suspected by TTE but TEE is more sensitive for detecting MVA, leaflet rupture and mitral regurgitation.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">2,4,22–25</span></a> Recently, a few reports have highlighted the role of real-time three-dimensional echocardiography to better define the anatomical features of MVA preoperatively.<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">16,26–28</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Echocardiography shows MVA as a localized saccular bulge of the mitral valve leaflet toward the left atrium communicating with the left ventricle, expanding in systole and collapsing in diastole.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">2</span></a> Diastolic expansion can occur in cases of MVA rupture or severe aortic regurgitation.<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">28</span></a> These lesions can vary from a few mm to 4 cm in diameter and may contain thrombi.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">8</span></a> The anterior leaflet is much more commonly involved than the posterior leaflet.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">2–4</span></a> The diagnosis of perforation is based on the presence of a high-velocity regurgitant jet traversing the aneurysm in systole and further supported by demonstration of an interrupted segment of the aneurysm by two-dimensional examination.<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">4,29</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">MVA must be differentiated from various abnormalities with similar echocardiographic appearance including severe mitral valve prolapse, diverticulum of the mitral valve, large valvular vegetation, flail valve leaflet, blood cyst of the papillary muscle, cystic atrial myxoma or non-endothelialized cyst of the mitral valve.<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">24,30</span></a> Color flow Doppler helps distinguish an aneurysm from other similar-looking abnormalities by demonstrating direct communication between the aneurysm and the left ventricle.<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">22</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Potential complications of these aneurysms include rupture, thromboembolism and recurrent infection. MVAs can also cause severe mitral regurgitation due to perforation of the aneurysm or as a result of leaflet coaptation defect caused by the mass effect of the aneurysm, and may precipitate rapid deterioration of hemodynamic status.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The optimal management strategy for MVAs has not yet been well defined. A few reports have shown that conservative management of uncomplicated MVAs, with close follow-up, is possible.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">2,31</span></a> In cases of MVA rupture or severe mitral regurgitation or if the patient needs aortic valve replacement surgery, then mitral valve surgery should be considered.<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">4,15,31</span></a> Conservative mitral valve surgery for aneurysm correction is not always possible; it depends on the degree of valve destruction and the anatomic disorder.<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">32</span></a> When it is unsuitable for repair,<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">32–34</span></a> mitral valve replacement may be the only viable option.<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">25,35,36</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In conclusion, MVAs are rare but potentially life-threatening complications and should be carefully considered in the evaluation of every patient with aortic valve endocarditis. We report a case with impressive images of aortic valve endocarditis complicated by perforated mitral valve aneurysm and severe mitral regurgitation, diagnosed by TEE. This case highlights the importance of early diagnosis with appropriate imaging and timely surgical intervention to prevent fatal outcomes.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Ethical disclosures</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Protection of human and animal subjects</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Confidentiality of data</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Right to privacy and informed consent</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres748719" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec751466" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres748718" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec751467" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Right to privacy and informed consent" ] ] ] 7 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of interest" ] 8 => array:2 [ "identificador" => "xack248855" "titulo" => "Acknowledgments" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-11-18" "fechaAceptado" => "2016-02-06" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec751466" "palabras" => array:5 [ 0 => "Mitral valve" 1 => "Aneurysm" 2 => "Aortic valve" 3 => "Endocarditis" 4 => "Echocardiography" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec751467" "palabras" => array:5 [ 0 => "Válvula mitral" 1 => "Aneurisma" 2 => "Válvula aórtica" 3 => "Endocardite" 4 => "Ecocardiografia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Mitral valve aneurysms are rare and occur most commonly in association with aortic valve endocarditis. Transesophageal echocardiography is the most sensitive imaging modality for the diagnosis of this entity and its potential complications, such as leaflet rupture and mitral regurgitation, which mandate prompt surgical intervention.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We present the case of a 70-year-old male patient with aortic valve endocarditis complicated with a ruptured aneurysm of the anterior mitral valve leaflet and associated severe mitral regurgitation, diagnosed by transesophageal echocardiography, with impressive images. We hypothesized that the aneurysm developed through direct extension of infection from the aortic valve or from a prolapsing aortic vegetation, with abscess formation and subsequent rupture and drainage. This case highlights the importance of appropriate imaging for early detection and timely surgical intervention (repair or replacement) to prevent fatal outcomes.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Os aneurismas da válvula mitral são raros e, habitualmente, encontram-se associados a endocardite da válvula aórtica. O ecocardiograma transesofágico é a modalidade imagiológica mais sensível para o diagnóstico desta entidade e das suas potenciais complicações, tais como perfuração e regurgitação mitral, que exigem intervenção cirúrgica urgente.</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Apresentamos o caso clínico de um doente de 70 anos, do sexo masculino, com endocardite da válvula aórtica complicada por aneurisma perfurado do folheto anterior da válvula mitral e regurgitação mitral grave associada, diagnosticada por ecocardiograma transesofágico com imagens muito ilustrativas. Admitimos como hipótese, mais provável, que o aneurisma se desenvolveu por extensão direta da infeção a partir da válvula aórtica ou do prolapso de uma vegetação aórtica, com formação de abcesso e subsequente rotura e drenagem. Este caso realça a importância das modalidades imagiológicas adequadas no diagnóstico precoce do aneurisma da válvula mitral e da intervenção cirúrgica atempada (plastia ou substituição) na prevenção de eventos fatais.</p></span>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 885 "Ancho" => 2501 "Tamanyo" => 207899 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Transthoracic echocardiogram (parasternal long-axis view). (A) Saccular bulge on the atrial side of the anterior mitral valve leaflet (small arrow) and a vegetation on the aortic valve prolapsing into the left ventricular outflow tract, in close contact with the anterior mitral valve leaflet (long arrow); (B) significant mitral regurgitation (color flow Doppler).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 886 "Ancho" => 2500 "Tamanyo" => 190904 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiogram. (A) 2-chamber view: saccular bulge (aneurysm) on the atrial side of the anterior mitral valve leaflet (arrow); (B) 5-chamber view: bilobular image (aneurysm) on the atrial side of the anterior mitral valve leaflet (arrow).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 892 "Ancho" => 2499 "Tamanyo" => 216240 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiogram (3-chamber view). (A) Ruptured aneurysm of the anterior mitral valve leaflet. The long arrow points to the entry site and the small arrow points to the exit site of the aneurysm; (B) color Doppler image showing two mitral regurgitation jets: a small jet through the leaflet coaptation point (small arrow) and a much more significant one through the aneurysm (long arrow).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:36 [ 0 => array:3 [ "identificador" => "bib0185" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mitral valve aneurysm: clinical features, echocardiographic-pathologic correlations" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "C. Reid" 1 => "A. Chandraratna" 2 => "E. Harrison" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "1983" "volumen" => "2" "paginaInicial" => "460" "paginaFinal" => "464" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/6875109" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S073510970000872X" "estado" => "S300" "issn" => "07351097" ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0190" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical, anatomic, and echocardiographic characteristics of aneurysms of the mitral valve" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "I. Vilacosta" 1 => "J. Román" 2 => "C. Sarriá" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Cardiol" "fecha" => "1999" "volumen" => "84" "paginaInicial" => "110" "paginaFinal" => "113" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10404866" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0195" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mitral valve aneurysm associated with aortic valve endocarditis and regurgitation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. Raval" 1 => "A. Menkis" 2 => "D. Boughner" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Heart Surg Forum" "fecha" => "2002" "volumen" => "5" "paginaInicial" => "298" "paginaFinal" => "299" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12538147" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0200" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical and echocardiographic evaluation of mitral valve aneurysms: a retrospective, single center study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A. Guler" 1 => "C. Karabay" 2 => "O. Gursoy" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s10554-014-0365-4" "Revista" => array:6 [ "tituloSerie" => "Int J Cardiovasc Imaging" "fecha" => "2014" "volumen" => "30" "paginaInicial" => "535" "paginaFinal" => "541" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24420419" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0205" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Aneurysm of heart valves" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "S. Jarcho" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Cardiol" "fecha" => "1968" "volumen" => "22" "paginaInicial" => "273" "paginaFinal" => "276" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/4874961" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0210" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The importance of the jet lesion in bacterial endocarditis involving the left heart. Surgical considerations" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "L. Gonzalez-Lavin" 1 => "M. Lise" 2 => "D. Ross" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Thorac Cardiovasc Surg" "fecha" => "1970" "volumen" => "59" "paginaInicial" => "185" "paginaFinal" => "192" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/5445473" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0215" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Transesophageal echocardiographic recognition of subaortic complications in aortic valve endocarditis. Clinical and surgical implications" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "D. Karalis" 1 => "R. Bansal" 2 => "A. Hauck" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Circulation" "fecha" => "1992" "volumen" => "86" "paginaInicial" => "353" "paginaFinal" => "362" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1638704" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0220" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Aneurysm of the mitral valve in subacute bacterial endocarditis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "N. Maclean" 1 => "M. Macdonal" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Br Heart J" "fecha" => "1957" "volumen" => "19" "paginaInicial" => "550" "paginaFinal" => "554" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/13471822" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0225" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Congenital obstructive mitral valve aneurysm" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "K. Kathir" 1 => "R.F. Dunn" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Int Med J" "fecha" => "2003" "volumen" => "33" "paginaInicial" => "541" "paginaFinal" => "542" ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0230" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mitral valve aneurysm revealed by cross-sectional echocardiography in a patient with mitral valve prolapse" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A. Ruckel" 1 => "A. Erbel" 2 => "B. Henkel" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Int J Cardiol" "fecha" => "1984" "volumen" => "6" "paginaInicial" => "633" "paginaFinal" => "637" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/6500753" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0735109799002582" "estado" => "S300" "issn" => "07351097" ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0235" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Perforated mitral valve aneurysm associated with Libman-Sacks endocarditis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "T. Takayama" 1 => "M. Teramura" 2 => "H. Sakai" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Int Med" "fecha" => "2008" "volumen" => "47" "paginaInicial" => "1605" "paginaFinal" => "1608" ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0240" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ruptured aneurysm of the mitral valve in a Marfan-like syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "G. Edynak" 1 => "A. Rawson" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Am J Cardiol" "fecha" => "1963" "volumen" => "11" "paginaInicial" => "674" "paginaFinal" => "677" ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0245" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pseudoxanthoma elasticum and mitral-valve prolapse" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M.G. Lebwohl" 1 => "D. Distefano" 2 => "P.G. Prioleau" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJM198207223070406" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "1982" "volumen" => "307" "paginaInicial" => "228" "paginaFinal" => "231" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7088072" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0250" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mitral valve aneurysm due to severe aortic valve regurgitation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "T. Cai" 1 => "J. Moody" 2 => "E. Sako" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Circulation" "fecha" => "1999" "volumen" => "100" "paginaInicial" => "e53" "paginaFinal" => "e56" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10491384" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0255" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mitral valve aneurysm with infective endocarditis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C. Gao" 1 => "C. Xiao" 2 => "B. Li" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S0003-4975(03)01602-3" "Revista" => array:6 [ "tituloSerie" => "Ann Thorac Surg" "fecha" => "2004" "volumen" => "78" "paginaInicial" => "2171" "paginaFinal" => "2173" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15561066" "web" => "Medline" ] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0260" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anterior mitral valve aneurysm perforation in a patient with pre-existing aortic regurgitation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "R. Citro" 1 => "A. Silverio" 2 => "R. Ascoli" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4081/monaldi.2012.114" "Revista" => array:6 [ "tituloSerie" => "Monaldi Arch Chest Dis" "fecha" => "2012" "volumen" => "78" "paginaInicial" => "210" "paginaFinal" => "211" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23659107" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0265" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The importance of secondary mitral valve involvement in primary aortic valve endocarditis. The mitral kissing vegetation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "C. Piper" 1 => "R. Hetzer" 2 => "R. Korfer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1053/euhj.2001.2689" "Revista" => array:6 [ "tituloSerie" => "Eur Heart J" "fecha" => "2002" "volumen" => "23" "paginaInicial" => "79" "paginaFinal" => "86" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11741365" "web" => "Medline" ] ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0270" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anterior mitral valve aneurysm perforation secondary to aortic valve endocarditis detected by Doppler colour flow mapping" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "P. Decroly" 1 => "J. Vandenbossche" 2 => "M. Englert" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Eur Heart J" "fecha" => "1989" "volumen" => "10" "paginaInicial" => "186" "paginaFinal" => "189" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2924788" "web" => "Medline" ] ] ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0275" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The importance of the echocardiographic diagnosis of a mycotic aneurysm of the mitral septal leaflet in infective endocarditis of the aortic valve: the surgical implication" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "C. Delqado" 1 => "R. Martín" 2 => "J. Vázquez" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Rev Esp Cardiol" "fecha" => "1991" "volumen" => "44" "paginaInicial" => "672" "paginaFinal" => "676" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1801096" "web" => "Medline" ] ] ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0280" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Review: mitral valve aneurysms in infective endocarditis: mechanisms, clinical recognition, and treatment" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J.J. Silbiger" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Heart Valve Dis" "fecha" => "2009" "volumen" => "18" "paginaInicial" => "476" "paginaFinal" => "480" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20099686" "web" => "Medline" ] ] ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0285" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "An unusual cause of severe mitral regurgitation in a patient with aortic valve endocarditis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M. Eisemen" 1 => "A. Schroeder" 2 => "S. Piotr" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1053/j.jvca.2013.10.021" "Revista" => array:6 [ "tituloSerie" => "J Cardiothorac Vasc Anesth" "fecha" => "2014" "volumen" => "28" "paginaInicial" => "1432" "paginaFinal" => "1434" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24461358" "web" => "Medline" ] ] ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0290" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The role of color flow Doppler in the echocardiographic diagnosis of mitral valve aneurysm" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M. Changlani" 1 => "D. Lieb" 2 => "D. Kaczkowski" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Am Soc Echocardiogr" "fecha" => "1993" "volumen" => "6" "paginaInicial" => "610" "paginaFinal" => "612" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8311968" "web" => "Medline" ] ] ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib0295" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Transesophageal versus transthoracic echocardiography for diagnosing mitral valve perforation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "D.G. Cziner" 1 => "B.P. Rosenzweig" 2 => "E.S. Katz" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Cardiol" "fecha" => "1992" "volumen" => "69" "paginaInicial" => "1495" "paginaFinal" => "1497" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1590245" "web" => "Medline" ] ] ] ] ] ] ] ] 23 => array:3 [ "identificador" => "bib0300" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mitral and tricuspid valve aneurysm evaluated by transesophageal echocardiography" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M. Mollod" 1 => "K. Felner" 2 => "J. Felner" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Cardiol" "fecha" => "1997" "volumen" => "79" "paginaInicial" => "1269" "paginaFinal" => "1272" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9164903" "web" => "Medline" ] ] ] ] ] ] ] ] 24 => array:3 [ "identificador" => "bib0305" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Aneurysm of the anterior leaflet of the mitral valve secondary to aortic valve endocarditis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "P. Marcos-Alberca" 1 => "J. Serrano" 2 => "I. Fernández-Rozas" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Am Soc Echocardiogr" "fecha" => "2000" "volumen" => "13" "paginaInicial" => "1050" "paginaFinal" => "1052" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11093109" "web" => "Medline" ] ] ] ] ] ] ] ] 25 => array:3 [ "identificador" => "bib0310" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "E72-6.8" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ruptured anterior mitral leaflet aneurysm in aortic valve infective endocarditis – evaluation by three-dimensional echocardiography" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "R. Kharwar" 1 => "A. Mohanty" 2 => "A. Sharma" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "Echocardiography" "fecha" => "2014" "volumen" => "31" ] ] ] ] ] ] 26 => array:3 [ "identificador" => "bib0315" "etiqueta" => "27" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Incremental value of three-dimensional transthoracic echocardiography in the assessment of ruptured aneurysm of anterior mitral leaflet" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "S. Vijay" 1 => "B. Tiwari" 2 => "M. Misra" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Ecocardiography" "fecha" => "2014" "volumen" => "31" "paginaInicial" => "E24" "paginaFinal" => "E26" ] ] ] ] ] ] 27 => array:3 [ "identificador" => "bib0320" "etiqueta" => "28" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ruptured aneurysm of the anterior mitral leaflet in aortic valve infective endocarditis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "I. Zegri" 1 => "V. Monivas" 2 => "S. Mingo" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/echo.12831" "Revista" => array:6 [ "tituloSerie" => "Echocardiography" "fecha" => "2015" "volumen" => "32" "paginaInicial" => "720" "paginaFinal" => "722" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25365965" "web" => "Medline" ] ] ] ] ] ] ] ] 28 => array:3 [ "identificador" => "bib0325" "etiqueta" => "29" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Perforated aneurysm of the anterior mitral valve – a Doppler and two-dimensional echocardiographic report" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A. Chua" 1 => "C. Chiang" 2 => "Y. Lee" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "1990" "volumen" => "97" "paginaInicial" => "753" "paginaFinal" => "754" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2306980" "web" => "Medline" ] ] ] ] ] ] ] ] 29 => array:3 [ "identificador" => "bib0330" "etiqueta" => "30" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anterior mitral valve aneurysm: a subaortic complication of aortic valve endocarditis: a case report and review of literature" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M. Rachko" 1 => "A. Safi" 2 => "D. Yeshou" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Heart Dis" "fecha" => "2001" "volumen" => "3" "paginaInicial" => "145" "paginaFinal" => "147" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11975784" "web" => "Medline" ] ] ] ] ] ] ] ] 30 => array:3 [ "identificador" => "bib0335" "etiqueta" => "31" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Conservative management of mitral valve aneurysm" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "K. Gin" 1 => "J. Boone" 2 => "C. Thompson" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Am Soc Echocardiogr" "fecha" => "1993" "volumen" => "6" "paginaInicial" => "613" "paginaFinal" => "618" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8311969" "web" => "Medline" ] ] ] ] ] ] ] ] 31 => array:3 [ "identificador" => "bib0340" "etiqueta" => "32" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Conservative surgical treatment of mitral valve aneurysm secondary to aortic valve endocarditis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M. Vieira" 1 => "P. Pomerantzeff" 2 => "L. Pillco" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Echocardiography" "fecha" => "2003" "volumen" => "20" "paginaInicial" => "435" "paginaFinal" => "438" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12848863" "web" => "Medline" ] ] ] ] ] ] ] ] 32 => array:3 [ "identificador" => "bib0345" "etiqueta" => "33" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ruptured true aneurysm of mitral valve. A complication of aortic valve endocarditis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "T. English" 1 => "M. Honey" 2 => "W. Cleland" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Br Heart J" "fecha" => "1972" "volumen" => "34" "paginaInicial" => "434" "paginaFinal" => "436" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/4259848" "web" => "Medline" ] ] ] ] ] ] ] ] 33 => array:3 [ "identificador" => "bib0350" "etiqueta" => "34" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Bicuspid aortic valve endocarditis complicated by mitral valve aneurysm" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "N. Ruparelia" 1 => "D. Lawrence" 2 => "A. Elkington" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1540-8191.2011.01243.x" "Revista" => array:6 [ "tituloSerie" => "J Card Surg" "fecha" => "2011" "volumen" => "26" "paginaInicial" => "284" "paginaFinal" => "286" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21447085" "web" => "Medline" ] ] ] ] ] ] ] ] 34 => array:3 [ "identificador" => "bib0355" "etiqueta" => "35" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mitral valve aneurysm associated with aortic valve regurgitation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "O. Gulmez" 1 => "L. Sade" 2 => "A. Yildirir" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Arch Turk Soc Cardiol" "fecha" => "2009" "volumen" => "37" "paginaInicial" => "263" "paginaFinal" => "265" ] ] ] ] ] ] 35 => array:3 [ "identificador" => "bib0360" "etiqueta" => "36" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "Published online 15 April 2015. Available at <a class="elsevierStyleInterRef" id="intr0005" href="http://casereports.bmj.com/content/2015/bcr-2014-209092.abstract">http://casereports.bmj.com/content/2015/bcr-2014-209092.abstract</a> [accessed 31.10.15]" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Large mitral valve aneurysm with infective endocarditis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "S. Uematsu" 1 => "K. Ashima" 2 => "H. Tomioka" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:2 [ "tituloSerie" => "BMJ Case Rep" "fecha" => "2015" ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack248855" "titulo" => "Acknowledgments" "texto" => "<p id="par0075" class="elsevierStylePara elsevierViewall">The authors wish to thank the Cardiothoracic Surgery Department of Centro Hospitalar S. João, Porto, for rapidly accepting the patient transfer.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/08702551/0000003500000011/v1_201610280519/S0870255116301871/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/S0870255116301871/v1_201610280519/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255116301871?idApp=UINPBA00004E" ]
| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 11 | 6 | 17 |
| 2024 Outubro | 71 | 43 | 114 |
| 2024 Setembro | 82 | 30 | 112 |
| 2024 Agosto | 89 | 26 | 115 |
| 2024 Julho | 80 | 50 | 130 |
| 2024 Junho | 55 | 31 | 86 |
| 2024 Maio | 81 | 28 | 109 |
| 2024 Abril | 54 | 30 | 84 |
| 2024 Maro | 52 | 36 | 88 |
| 2024 Fevereiro | 57 | 37 | 94 |
| 2024 Janeiro | 56 | 31 | 87 |
| 2023 Dezembro | 55 | 27 | 82 |
| 2023 Novembro | 63 | 27 | 90 |
| 2023 Outubro | 44 | 13 | 57 |
| 2023 Setembro | 58 | 23 | 81 |
| 2023 Agosto | 54 | 15 | 69 |
| 2023 Julho | 46 | 8 | 54 |
| 2023 Junho | 51 | 20 | 71 |
| 2023 Maio | 66 | 22 | 88 |
| 2023 Abril | 44 | 2 | 46 |
| 2023 Maro | 95 | 23 | 118 |
| 2023 Fevereiro | 76 | 24 | 100 |
| 2023 Janeiro | 32 | 16 | 48 |
| 2022 Dezembro | 71 | 18 | 89 |
| 2022 Novembro | 88 | 26 | 114 |
| 2022 Outubro | 83 | 34 | 117 |
| 2022 Setembro | 73 | 38 | 111 |
| 2022 Agosto | 58 | 32 | 90 |
| 2022 Julho | 65 | 42 | 107 |
| 2022 Junho | 45 | 21 | 66 |
| 2022 Maio | 67 | 27 | 94 |
| 2022 Abril | 141 | 33 | 174 |
| 2022 Maro | 70 | 51 | 121 |
| 2022 Fevereiro | 50 | 21 | 71 |
| 2022 Janeiro | 60 | 22 | 82 |
| 2021 Dezembro | 72 | 29 | 101 |
| 2021 Novembro | 77 | 36 | 113 |
| 2021 Outubro | 70 | 52 | 122 |
| 2021 Setembro | 49 | 27 | 76 |
| 2021 Agosto | 57 | 41 | 98 |
| 2021 Julho | 47 | 27 | 74 |
| 2021 Junho | 72 | 26 | 98 |
| 2021 Maio | 76 | 44 | 120 |
| 2021 Abril | 94 | 50 | 144 |
| 2021 Maro | 81 | 21 | 102 |
| 2021 Fevereiro | 113 | 22 | 135 |
| 2021 Janeiro | 43 | 15 | 58 |
| 2020 Dezembro | 95 | 16 | 111 |
| 2020 Novembro | 65 | 28 | 93 |
| 2020 Outubro | 64 | 15 | 79 |
| 2020 Setembro | 112 | 26 | 138 |
| 2020 Agosto | 53 | 12 | 65 |
| 2020 Julho | 95 | 12 | 107 |
| 2020 Junho | 80 | 21 | 101 |
| 2020 Maio | 121 | 8 | 129 |
| 2020 Abril | 106 | 21 | 127 |
| 2020 Maro | 116 | 15 | 131 |
| 2020 Fevereiro | 282 | 16 | 298 |
| 2020 Janeiro | 116 | 10 | 126 |
| 2019 Dezembro | 189 | 21 | 210 |
| 2019 Novembro | 226 | 14 | 240 |
| 2019 Outubro | 154 | 17 | 171 |
| 2019 Setembro | 172 | 6 | 178 |
| 2019 Agosto | 156 | 9 | 165 |
| 2019 Julho | 146 | 9 | 155 |
| 2019 Junho | 125 | 21 | 146 |
| 2019 Maio | 112 | 15 | 127 |
| 2019 Abril | 110 | 21 | 131 |
| 2019 Maro | 105 | 13 | 118 |
| 2019 Fevereiro | 181 | 17 | 198 |
| 2019 Janeiro | 145 | 15 | 160 |
| 2018 Dezembro | 92 | 15 | 107 |
| 2018 Novembro | 180 | 23 | 203 |
| 2018 Outubro | 154 | 22 | 176 |
| 2018 Setembro | 73 | 10 | 83 |
| 2018 Agosto | 54 | 13 | 67 |
| 2018 Julho | 39 | 4 | 43 |
| 2018 Junho | 56 | 5 | 61 |
| 2018 Maio | 48 | 15 | 63 |
| 2018 Abril | 65 | 15 | 80 |
| 2018 Maro | 64 | 9 | 73 |
| 2018 Fevereiro | 29 | 8 | 37 |
| 2018 Janeiro | 33 | 11 | 44 |
| 2017 Dezembro | 70 | 11 | 81 |
| 2017 Novembro | 66 | 10 | 76 |
| 2017 Outubro | 60 | 14 | 74 |
| 2017 Setembro | 53 | 10 | 63 |
| 2017 Agosto | 50 | 12 | 62 |
| 2017 Julho | 43 | 11 | 54 |
| 2017 Junho | 46 | 17 | 63 |
| 2017 Maio | 55 | 19 | 74 |
| 2017 Abril | 35 | 10 | 45 |
| 2017 Maro | 42 | 11 | 53 |
| 2017 Fevereiro | 69 | 10 | 79 |
| 2017 Janeiro | 39 | 8 | 47 |
| 2016 Dezembro | 64 | 34 | 98 |
| 2016 Novembro | 68 | 53 | 121 |
| 2016 Outubro | 33 | 31 | 64 |
Mostrar tudo
