Case report
Percutaneous treatment of tricuspid regurgitation: A new therapeutic horizon
Intervenção percutânea na regurgitação tricúspide: um novo horizonte terapêutico
Eduardo M. Vilela
, José Ribeiro, João Almeida, Marlene Fonseca, Adelaide Dias, João Primo, Pedro Braga, Vasco Gama
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Hospital Center of Vila Nova de Gaia/Espinho, Cardiology Department, Vila Nova de Gaia/Espinho, Portugal
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Vilela, José Ribeiro, João Almeida, Marlene Fonseca, Adelaide Dias, João Primo, Pedro Braga, Vasco Gama" "autores" => array:8 [ 0 => array:4 [ "nombre" => "Eduardo M." "apellidos" => "Vilela" "email" => array:1 [ 0 => "eduardomvilela@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "José" "apellidos" => "Ribeiro" ] 2 => array:2 [ "nombre" => "João" "apellidos" => "Almeida" ] 3 => array:2 [ "nombre" => "Marlene" "apellidos" => "Fonseca" ] 4 => array:2 [ "nombre" => "Adelaide" "apellidos" => "Dias" ] 5 => array:2 [ "nombre" => "João" "apellidos" => "Primo" ] 6 => array:2 [ "nombre" => "Pedro" "apellidos" => "Braga" ] 7 => array:2 [ "nombre" => "Vasco" "apellidos" => "Gama" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Hospital Center of Vila Nova de Gaia/Espinho, Cardiology Department, Vila Nova de Gaia/Espinho, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Intervenção percutânea na regurgitação tricúspide: um novo horizonte terapêutico" ] ] "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" => 1309 "Ancho" => 3000 "Tamanyo" => 294304 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Mitralign system implantation, as assessed by TEE (see text for description).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Tricuspid regurgitation (TR) is a clinical entity with significant prevalence,<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1,2</span></a> and is frequently associated with other valve disorders (especially mitral valve disease).<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1,3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In western countries, functional (or secondary) TR due to right ventricle (RV) and/or tricuspid annular dilatation in the context of pressure or volume overload (such as left-sided valve disease, pulmonary hypertension or RV dysfunction) is the most common etiology of TR.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Although TR may be well tolerated, particularly in its early stages, progression of the disease often leads to right heart failure.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">4,6</span></a> Contrary to previous conceptions regarding the natural history of TR, contemporary data show that TR may progress after left-sided valve intervention.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1,6–8</span></a> This is relevant given that, contrary to early tricuspid intervention, re-operation is often associated with a high risk.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Several studies have also shown that, in different clinical contexts, TR is associated with adverse outcomes, namely mortality.<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">6,9–12</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">These considerations have led to a new interest in the field of percutaneous intervention in functional TR,<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">4,8</span></a> which could provide a new option in high-risk patients. However, challenges concerning the anatomy of the tricuspid valve as well as the impact of hemodynamic factors in its adequate quantification have been important considerations.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">4–6,8</span></a> Different devices have been designed in an attempt to address this issue.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a> One such device, the Mitralign system (Mitralign Inc., Tewksbury, Massachusetts), originally developed in the context of functional mitral regurgitation,<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">13</span></a> has been successfully implanted in a patient with severe TR.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">14</span></a> This device replicates the Kay procedure, first described over 50 years ago, in which the tricuspid valve is converted into a mitral-like valve after plication of the valve annulus.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">15</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">We report the first case in Portugal to our knowledge of percutaneous TR treatment with the Mitralign system.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Summary description</span><p id="par0035" class="elsevierStylePara elsevierViewall">The technique used was similar to the one described by Schofer <span class="elsevierStyleItalic">et al.</span><a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">14</span></a> In short, with this technique, the Mitralign system is used to place pledgeted sutures (via a trans-jugular approach) so that the tricuspid valve annulus can be plicated, thus leading to a bicuspidization of this valve.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">4,8,14</span></a> [Supplemental video 1 shows the different steps of the procedure, as assessed by transesophageal echocardiogram: A (pre-procedure, surgeon's view of the tricuspid valve), B–C (implantation of the first pledget), D (implantation of the second pledget), E–G (locking and bicuspidization of valve), H (post-procedure, surgeon's view of the tricuspid valve)]</p><p id="par0040" class="elsevierStylePara elsevierViewall">Pre-procedure planning included transesophageal echocardiography (TEE) in order to assess tricuspid valve anatomy and physiology. The procedure <span class="elsevierStyleItalic">per se</span> was done with 2D and 3D TEE guidance, under general anesthesia, with anticoagulation by unfractionated heparin (under activated clotting time [ACT] guidance). Arterial access was obtained via a 6F right femoral cannula, and venous access was obtained via two 14F right jugular cannulas.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Case report</span><p id="par0045" class="elsevierStylePara elsevierViewall">The patient was a 77-year-old woman, who was referred to our department due to symptomatic heart failure despite diuretic therapy. She had undergone mitral valve replacement (with a mechanical valve prosthesis) ten years prior to referral. Other relevant pathological history included permanent atrial fibrillation and dyslipidemia.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Her TEE showed biatrial dilatation, mild aortic regurgitation, a normally implanted and adequately functioning mitral valve prosthesis, moderate-to-severe TR and preserved biventricular function (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">She had been assessed for possible surgical intervention, but due to perceived high surgical risk (namely in the context of previous cardiac intervention and overall clinical status, the patient presenting with a EuroSCORE [European System for Cardiac Operative Risk Evaluation] II score of 10.59% and a Log EuroSCORE of 29.30%), she was put forward for a percutaneous approach. After discussion and review of the case, she was accepted for percutaneous tricuspid valve intervention with the Mitralign system (compassionate use of the procedure).</p><p id="par0060" class="elsevierStylePara elsevierViewall">Prior to implantation, her TEE showed a tricuspid annular area of 13 cm<span class="elsevierStyleSup">2</span> and an effective regurgitant orifice (ERO) area (calculated by the proximal isovelocity surface area [PISA] method) of 0.4 cm<span class="elsevierStyleSup">2</span>.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The procedure was undertaken as previously described<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">14</span></a> (supplemental video 1). A first pledget was placed in the tricuspid ring in the commissure between the septal and the posterior leaflet (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>A); a second pledget was placed at about 24 mm in the valve annulus near the edge of the posterior leaflet. Subsequently, plication of the posterior leaflet was performed, with consequent bicuspidization of the valve, thus reducing the area of the valve ring to 9 cm<span class="elsevierStyleSup">2</span> (<a class="elsevierStyleCrossRef" href="#fig0010">Figures 2B and 2C</a>). No immediate complications arose.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">After the procedure, the patient developed a femoral hematoma, which resolved with supportive care without the need for interventional treatment or blood transfusion. She had a favorable clinical course, and the remainder of hospitalization was uneventful, with the patient being discharged eight days after admission.</p><p id="par0075" class="elsevierStylePara elsevierViewall">At the one-month follow-up, the patient maintained optimized pharmacological therapy, and was clinically improved (as self-reported), completing 280 meters during a six-minute walk test (<span class="elsevierStyleItalic">versus</span> 225 meters prior to intervention). Although clinically improved, diuretic utilization was maintained, and no down-grading of dose was performed at this follow-up.</p><p id="par0080" class="elsevierStylePara elsevierViewall">A follow-up TEE showed mild-to-moderate TR, with an ERO area (calculated by PISA) of 0.2 cm<span class="elsevierStyleSup">2</span> and a regurgitant volume of 18 mL (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>), and preserved RV function.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="par0085" class="elsevierStylePara elsevierViewall">We report the successful use of the Mitralign system in the treatment of a case of functional TR in a patient at high operatory risk (deemed not to be a candidate for surgical treatment), who was symptomatic despite diuretic therapy. Although she continued to require optimized pharmacological treatment, the patient's symptoms improved with a significant reduction in the degree of TR as assessed by TEE.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Functional TR occurring in patients after left-sided valve intervention presents important challenges, namely an increased surgical risk.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">3,16</span></a> Various factors, such as advanced age, frailty and different comorbidities add to this risk and, as such, there is still an unmet need in terms of the management of functional TR.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">17</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Imaging techniques (with a special emphasis on echocardiography) are becoming increasingly crucial in the different stages of percutaneous procedures.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">18,19</span></a> In the case reported above, the use of echocardiography at different time points, and especially during the procedure (supplemental video 1; <a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>), is critical for a good outcome. However, other modalities, such as cardiac computed tomography (which facilitates a precise assessment of the tricuspid annulus and surrounding structures, and also of possible access sites) are also gaining a prominent role in different percutaneous approaches.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">18,19</span></a> As different systems are being assessed in clinical practice, the interplay between imaging and intervention will become increasingly important.<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">17–19</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The limitations of our report include the fact that only one case, and with a limited follow-up (of only one month), was presented. As such, more data with a higher number of patients will be needed in order to further clarify the role of this procedure in routine clinical practice.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">20</span></a> The impact of this percutaneous tricuspid valve intervention in terms of morbidity (namely, if the symptomatic improvement will be maintained in mid- and long-term follow-up, and what the optimal pharmacological management will be after the intervention) and especially mortality, also need further clarification. Longer follow-up would also be important to see if a downgrade in diuretic therapy would be possible, while maintaining clinical improvement. In addition, the fact that this procedure is technically demanding (both in terms of the valve procedure <span class="elsevierStyleItalic">per se</span>, and the need for advanced imaging),<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a> is an important consideration. However, taking into account the scarcity of data concerning percutaneous TR intervention with this device,<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">4,8,14</span></a> our results concur with those previously reported, and are promising given the clinical and echocardiographic improvement of the patient.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Although this is a new field, this description adds to our knowledge concerning percutaneous tricuspid valve intervention, a field whose complexity is only just beginning to be grasped.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflicts of interest</span><p id="par0110" 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" => "xres1015162" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec973800" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1015163" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec973799" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Summary description" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Case report" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-10-03" "fechaAceptado" => "2017-01-22" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec973800" "palabras" => array:3 [ 0 => "Tricuspid regurgitation" 1 => "Mitralign" 2 => "Heart failure" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec973799" "palabras" => array:3 [ 0 => "Insuficiência tricúspide" 1 => "Mitralign" 2 => "Insuficiência cardíaca" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Functional tricuspid regurgitation is a prevalent disease, especially among patients with other valve disorders, and is associated with significant morbidity and mortality. Its management is challenging, and many patients deemed at high surgical risk are managed conservatively. Despite optimization of pharmacological treatment, many patients continue to be symptomatic, thus leading to interest in percutaneous interventional techniques. The Mitralign system has recently been used for the treatment of functional tricuspid regurgitation, with favorable clinical and imaging results.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We report the first case in Portugal to our knowledge of percutaneous tricuspid regurgitation treatment with the Mitralign system.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A insuficiência tricúspide funcional é uma patologia prevalente, especialmente em doentes com outras valvulopatias, podendo estar associada a importante morbilidade e mortalidade. A sua abordagem é desafiante, sendo que diversos doentes considerados de alto risco cirúrgico são abordados conservadoramente. Apesar do aprimoramento farmacológico, muitos mantêm sintomas, o que leva ao interesse em formas de tratamento percutâneo. O sistema Mitralign foi recentemente usado nesse contexto, com resultados clínicos e imagiológicos favoráveis.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Reportamos aquele que é, no nosso conhecimento, o primeiro caso de tratamento percutâneo de insuficiência tricúspide com o sistema Mitralign, em Portugal.</p></span>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0120" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia><elsevierMultimedia ident="upi0010"></elsevierMultimedia><elsevierMultimedia ident="upi0015"></elsevierMultimedia><elsevierMultimedia ident="upi0020"></elsevierMultimedia><elsevierMultimedia ident="upi0025"></elsevierMultimedia><elsevierMultimedia ident="upi0030"></elsevierMultimedia><elsevierMultimedia ident="upi0035"></elsevierMultimedia><elsevierMultimedia ident="upi0040"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary material" "identificador" => "sec0035" ] ] ] ] "multimedia" => array:11 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1138 "Ancho" => 1583 "Tamanyo" => 147939 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Pre-procedure TEE showing significant tricuspid regurgitation.</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" => 1309 "Ancho" => 3000 "Tamanyo" => 294304 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Mitralign system implantation, as assessed by TEE (see text for description).</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" => 1407 "Ancho" => 3000 "Tamanyo" => 359407 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Follow-up TEE showing reduced tricuspid regurgitation.</p>" ] ] 3 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.mp4" "ficheroTamanyo" => 162299 "Video" => array:2 [ "mp4" => array:5 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] ] 4 => array:5 [ "identificador" => "upi0010" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" 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"fichero" => "mmc6.m4v" "poster" => "mmc6.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] ] 9 => array:5 [ "identificador" => "upi0035" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc7.mp4" "ficheroTamanyo" => 134633 "Video" => array:2 [ "mp4" => array:5 [ "fichero" => "mmc7.m4v" "poster" => "mmc7.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "flv" => array:5 [ "fichero" => "mmc7.flv" "poster" => "mmc7.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] ] 10 => array:5 [ "identificador" => "upi0040" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc8.mp4" "ficheroTamanyo" => 509816 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc8.flv" "poster" => "mmc8.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:5 [ "fichero" => "mmc8.m4v" "poster" => "mmc8.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] ] ] 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| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 12 | 3 | 15 |
| 2024 Outubro | 55 | 33 | 88 |
| 2024 Setembro | 72 | 39 | 111 |
| 2024 Agosto | 66 | 36 | 102 |
| 2024 Julho | 38 | 30 | 68 |
| 2024 Junho | 40 | 28 | 68 |
| 2024 Maio | 35 | 27 | 62 |
| 2024 Abril | 44 | 25 | 69 |
| 2024 Maro | 44 | 23 | 67 |
| 2024 Fevereiro | 35 | 16 | 51 |
| 2024 Janeiro | 39 | 21 | 60 |
| 2023 Dezembro | 32 | 25 | 57 |
| 2023 Novembro | 43 | 24 | 67 |
| 2023 Outubro | 47 | 21 | 68 |
| 2023 Setembro | 36 | 25 | 61 |
| 2023 Agosto | 33 | 25 | 58 |
| 2023 Julho | 41 | 6 | 47 |
| 2023 Junho | 26 | 10 | 36 |
| 2023 Maio | 54 | 23 | 77 |
| 2023 Abril | 66 | 7 | 73 |
| 2023 Maro | 48 | 20 | 68 |
| 2023 Fevereiro | 37 | 23 | 60 |
| 2023 Janeiro | 19 | 17 | 36 |
| 2022 Dezembro | 52 | 22 | 74 |
| 2022 Novembro | 54 | 29 | 83 |
| 2022 Outubro | 55 | 31 | 86 |
| 2022 Setembro | 39 | 51 | 90 |
| 2022 Agosto | 46 | 28 | 74 |
| 2022 Julho | 38 | 45 | 83 |
| 2022 Junho | 33 | 33 | 66 |
| 2022 Maio | 32 | 33 | 65 |
| 2022 Abril | 43 | 47 | 90 |
| 2022 Maro | 36 | 60 | 96 |
| 2022 Fevereiro | 31 | 40 | 71 |
| 2022 Janeiro | 42 | 31 | 73 |
| 2021 Dezembro | 35 | 33 | 68 |
| 2021 Novembro | 43 | 37 | 80 |
| 2021 Outubro | 81 | 36 | 117 |
| 2021 Setembro | 29 | 24 | 53 |
| 2021 Agosto | 37 | 41 | 78 |
| 2021 Julho | 32 | 23 | 55 |
| 2021 Junho | 40 | 25 | 65 |
| 2021 Maio | 48 | 37 | 85 |
| 2021 Abril | 85 | 94 | 179 |
| 2021 Maro | 76 | 21 | 97 |
| 2021 Fevereiro | 70 | 6 | 76 |
| 2021 Janeiro | 41 | 16 | 57 |
| 2020 Dezembro | 55 | 15 | 70 |
| 2020 Novembro | 38 | 12 | 50 |
| 2020 Outubro | 32 | 15 | 47 |
| 2020 Setembro | 94 | 30 | 124 |
| 2020 Agosto | 44 | 4 | 48 |
| 2020 Julho | 44 | 16 | 60 |
| 2020 Junho | 52 | 23 | 75 |
| 2020 Maio | 49 | 32 | 81 |
| 2020 Abril | 62 | 32 | 94 |
| 2020 Maro | 39 | 13 | 52 |
| 2020 Fevereiro | 133 | 19 | 152 |
| 2020 Janeiro | 49 | 11 | 60 |
| 2019 Dezembro | 53 | 20 | 73 |
| 2019 Novembro | 26 | 16 | 42 |
| 2019 Outubro | 80 | 14 | 94 |
| 2019 Setembro | 82 | 8 | 90 |
| 2019 Agosto | 72 | 9 | 81 |
| 2019 Julho | 63 | 9 | 72 |
| 2019 Junho | 63 | 19 | 82 |
| 2019 Maio | 62 | 9 | 71 |
| 2019 Abril | 48 | 23 | 71 |
| 2019 Maro | 68 | 22 | 90 |
| 2019 Fevereiro | 52 | 7 | 59 |
| 2019 Janeiro | 46 | 5 | 51 |
| 2018 Dezembro | 43 | 14 | 57 |
| 2018 Novembro | 85 | 15 | 100 |
| 2018 Outubro | 203 | 26 | 229 |
| 2018 Setembro | 57 | 9 | 66 |
| 2018 Agosto | 50 | 62 | 112 |
| 2018 Julho | 51 | 42 | 93 |
| 2018 Junho | 26 | 13 | 39 |
| 2018 Maio | 42 | 19 | 61 |
| 2018 Abril | 45 | 58 | 103 |
| 2018 Maro | 2 | 44 | 46 |
| 2018 Fevereiro | 4 | 51 | 55 |
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