Original article
Treatment of Fallot tetralogy with a transannular patch. Six years follow-up
Tratamiento de la tetralogía de Fallot con parche transanular. Seguimiento a 6 años
Myriam Galicia-Tornella, Alfonso Reyes-Lópezb, Sergio Ruíz-Gonzálezb, Alejandro Bolio-Cerdánb, Alejandro González-Ojedac, Clotilde Fuentes-Orozcoc,
Corresponding author
clotilde.fuentes@gmail.com
Corresponding author at: Belisario Domínguez #1000, Colonia Independencia Oblatos, C.P. 44329 Guadalajara, Jalisco, Mexico. Tel.: +33 3618 2760.
Corresponding author at: Belisario Domínguez #1000, Colonia Independencia Oblatos, C.P. 44329 Guadalajara, Jalisco, Mexico. Tel.: +33 3618 2760.
a Departamento de Cirugía Cardiotorácica Pediátrica, Unidad Médica de Alta Especialidad, Hospital de Especialidades del Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, Mexico
b Departamento de Cirugía Cardiovascular, Hospital Infantil de México “Federico Gómez”, México, D.F., Mexico
c Unidad de Investigación Médica en Epidemiologia Clínica, Unidad Médica de Alta Especialidad, Hospital de Especialidades del Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, Mexico
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Tel.: +33 3618 2760." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tratamiento de la tetralogía de Fallot con parche transanular. Seguimiento a 6 años" ] ] "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" => 1213 "Ancho" => 850 "Tamanyo" => 226096 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Closure of interventricular communication.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">Fallot Tetralogy is the most common form of cyanotic congenital heart disease, and accounts for 7–10% of all congenital cardiopathies.<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">1–7</span></a> If it is not corrected surgically, Fallot tetralogy is progressive with high mortality (>35% die in the first year of life, and 50% at 3 years of age),<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">3,4,7</span></a> total correction is the treatment of choice, and this has low perioperative mortality (2–5%), even in neonates,<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">7–12</span></a> and high long term survival rates (95.7% at 10 years, 93.5% at 20, and 85% at 36).<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">7,13,14</span></a> It is considered the cyanogenic cardiopathy with the longest survival (mean age of 30).<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">7</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Total correction has diverse complications, which include: progressive ventricular dilatation due to residual obstruction of the outflow tract; severe pulmonary valve insufficiency, other residual lesions, arrhythmia, and sudden death. It is observed that reoperation is needed in 6–10% of cases up to 10–20 years from the initial correction.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">13</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The need to insert a transannular patch during reconstruction surgery of the right ventricular outflow results in pulmonary insufficiency which, associated with other residual defects (interventricular communication, obstruction in the pulmonary branches), creates volume overload, ventricular dysfunction requiring subsequent reinterventions, and even pulmonary valve replacement. It has been demonstrated that the surgical technique determines postoperative recovery, and long-term results.<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">14–17</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Over the past decade, 338 cases (26%) have been treated in the <span class="elsevierStyleItalic">Hospital Infantil de México Federico Gómez</span>, of whom 4.4% of the total number of congenital cardiopathies had Fallot tetralogy.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The purpose of this study was to assess the patients who underwent total correction of Fallot tetralogy with a transannular patch between January 2000 and December 2009.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">A case series was used which included fifty-two patients with Fallot tetralogy, treated surgically by total correction with transannular patch in the Cardiovascular Surgery Department of the <span class="elsevierStyleItalic">Hospital Infantil de México Federico Gómez</span>, between 1 January 2000 and 31 December 2009. Twenty-three boys and 29 girls were registered. The mean age during the correction was 4<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2 years of age. Four patients presented genopathies (Down's syndrome: 3; Williams syndrome: one).</p><p id="par0035" class="elsevierStylePara elsevierViewall">The diagnosis of Fallot tetralogy was made by echocardiogram in all cases. Twenty-two cases were reported to have associated cardiac anomalies: right-sided aortic arch presented in 10 patients; single coronary ostium in 4 cases; double superior vena cava in 4 cases; agenesis of valves, and left branch of the pulmonary artery in 2 patients; complete atrioventricular canal defect in one patient, and finally, <span class="elsevierStyleItalic">situs inversus</span> in one patient.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The data were obtained from the last medical consultation, which included: full physical examination, standard electrocardiogram (12 lead) and/or 24<span class="elsevierStyleHsp" style=""></span>h ambulatory cardiac monitoring (Holter), chest X-ray, echocardiogram (two-dimensional, M mode, three-dimensional, conventional and tissue Doppler).</p><p id="par0045" class="elsevierStylePara elsevierViewall">The study variables were: perioperative morbidity and mortality occurring within the first 30 postoperative days, determined by: (1) causes associated with the surgical procedure: residual obstruction of the proximal and distal right ventricular outflow tract (gradient ><span class="elsevierStyleHsp" style=""></span>50<span class="elsevierStyleHsp" style=""></span>mmHg and right ventricle/left ventricle pressure ratio ><span class="elsevierStyleHsp" style=""></span>0.75), residual interventricular communication with haemodynamic repercussions, cardiac conduction and/or rhythm disorders, diaphragm paralysis; (2) causes not associated with the surgical procedure: acute cardiac failure, pleural effusion, acute renal failure, pneumonia, neurological alterations, pancreatitis; and (3) reoperations.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Late morbidity and mortality</span><p id="par0050" class="elsevierStylePara elsevierViewall">Morbidity and mortality after the first 30 postoperative days was considered, and included: (1) right ventricular dysfunction due to pulmonary insufficiency, with/without stenosis of the pulmonary branches; (2) residual/recurrent obstruction of the proximal or distal right ventricular outflow tract, with/without right ventricle dysfunction; (3) residual interventricular communication with haemodynamic repercussions; (4) reoperations; and (5) arrhythmias and sudden death.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Surgical technique</span><p id="par0055" class="elsevierStylePara elsevierViewall">The heart was exposed by midline sternotomy, a patch of pericardium was resected (treated with 0.6% glutaraldehyde for 10<span class="elsevierStyleHsp" style=""></span>min and washed with saline solution), to reconstruct the right ventricular outflow tract, as can be seen in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>. Previous systemic-to-pulmonary shunts were ligated. Extracorporeal circulation and moderate hyperthermia were used (naso-pharyngeal temperature of 28–32<span class="elsevierStyleHsp" style=""></span>°C), circulatory arrest with profound hypothermia was used in 2 cases to enable visualisation during closure of the interventricular communication, and correction of the complete atrioventricular canal. Myocardial protection was achieved with intermittent administration (every 30<span class="elsevierStyleHsp" style=""></span>min) of cardioplegic solution (Benson Roe) and local hypothermia.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">The interventricular communication was closed through the right atrium in 37 patients and through a right ventriculostomy in 15; a Dacron patch was used in all cases. Muscle was resected from the free infundibular wall and/or fibrous tissue, annular hypoplasia was confirmed, and hypoplasia of the pulmonary branches with Hegar's graduated dilators. The right ventricular outflow tract was exposed by ventriculostomy which was as limited as possible (5<span class="elsevierStyleHsp" style=""></span>mm approximately), just in order for the patch to effectively widen the pulmonary ring. In the case of stenosis, the transannular incision was increased up to the pulmonary branches, extending the patch beyond the stenosis, which in the case of the left branch was after the ductus arteriosis.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Simultaneously, on widening the ring, the pulmonary valve function was preserved as far as possible, in 3 cases a monocuspid valve was made with autologous pericardium. We use the strategy of the limited transannular patch; i.e., the transannular patch was made to restrict the diameter of the pulmonary ring at a <span class="elsevierStyleItalic">z</span> value of ≥<span class="elsevierStyleHsp" style=""></span>2 using a Hegar's dilator as a guide.</p><p id="par0070" class="elsevierStylePara elsevierViewall">All the atrial septal defects were closed, as can be seen in <a class="elsevierStyleCrossRefs" href="#fig0010">Figs. 2 and 3</a>. During the transoperative period right ventricular/left ventricular pressure ratio measurement<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>two-thirds systemic pressure (measured directly), and right ventricular outflow tract gradient ><span class="elsevierStyleHsp" style=""></span>50<span class="elsevierStyleHsp" style=""></span>mmHg (estimated by transoperative echocardiogram) occurred in 7 patients who required enlargement of their ventriculostomy, beyond the length of the infundibular septum (5 cases), and extension of the patch to the level of the left branch (2 cases). Extracorporeal circulation was stopped, cannulae removed, and the sternotomy closed. One patient was managed with an open chest.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Statistical analysis</span><p id="par0075" class="elsevierStylePara elsevierViewall">Descriptive statistics; raw numbers and proportions for qualitative variables; means and their standard deviation for quantitative variables. Inferential statistics by univariate analysis, and determination of odds ratios, and 95% confidence intervals.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Windows SPSS (version 17; IBM, Armonk, NY, USA) was used. All <span class="elsevierStyleItalic">p</span> values<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05 were considered statistically significant.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Ethical considerations</span><p id="par0085" class="elsevierStylePara elsevierViewall">Ethical aspects: the basic principles according to the 2002 Helsinki Declaration and the <span class="elsevierStyleItalic">Ley General de Salud</span> (General Health Act) on research were followed, in order to ensure the maximum safety of the study population. The protocol was approved beforehand by the Local Health Research Committee of the main hospital.</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><p id="par0090" class="elsevierStylePara elsevierViewall">In our series there were 52 cases with total transannular patch or arterioventricular repair.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Fifteen patients presented with perioperative complications associated with surgical correction, which included: residual obstruction of the right ventricular outflow tract in 8 cases, myocardial ischaemia in 2, rhythm and/or conduction disorders in 4, diaphragm paralysis in one case.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Nine of the cases required early reoperation. Six cases due to residual obstruction documented during the transoperative period by echocardiogram, and direct measurement of right ventricular/left ventricular pressure; 4 required enlargement of the right ventricular outflow tract, and 2 of the left pulmonary branch: 2 cases had atrioventricular block, reoperated in order to insert a permanent pacemaker, and one case to perform a diaphragmatic plication.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Late morbidity occurred in 14 cases. Severe right ventricular dysfunction due to severe pulmonary insufficiency occurred in 9 patients, and due to severe pulmonary insufficiency with recurrent distal obstruction in 2 cases; recurrent distal obstruction with mild-moderate ventricular dysfunction occurred in another 2 cases. Three of these patients were reoperated: closure of residual interventricular communication in one case, and pulmonary valve replacement with bioprosthesis in 2.</p><p id="par0110" class="elsevierStylePara elsevierViewall">There were six cases of periooperative mortality in the immediate postoperative period, 5 due to residual obstruction of the right ventricular outflow tract, and one due to myocardial ischaemia. Early reoperation preceded 50% of the fatal cases (OR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>5.5, CI 95%: 1.3–22.5).</p><p id="par0115" class="elsevierStylePara elsevierViewall">The results were analysed by univariate analysis of the risk factors for severe ventricular dilatation of the 46 surviving patients. Statistically significant differences were found with pulmonary insufficiency (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.001); QRS complex<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>160<span class="elsevierStyleHsp" style=""></span>ms (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.001); cardiothoracic index<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>0.60 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.048) and tricuspid insufficiency (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.001). Forty-six patients survived initial repair of Fallot tetralogy with transannular patch at 10 years (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discussion</span><p id="par0120" class="elsevierStylePara elsevierViewall">Total repair of Fallot tetralogy is the method of choice for most cases. There are few studies on repair in neonates, and they are associated with a long stay in the intensive care unit, with increased use of circulatory arrest and transannular patch, and a high reoperation rate of 25% to 30% at 5 years from the initial operation.<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">18,19</span></a> The European Association for Cardio-Thoracic Surgery Database (EACTS CDB)<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">20</span></a> reports a 7.8% mortality due to primary repair in neonates; whereas the Southern Thoracic Society reports 7.3%, better results being obtained when the repair is performed in infants between 3 and 12 months old.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">18</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">In the past 5 years, the policy in this highly specialised hospital has been to perform primary repair in under 2-year olds, as surgical mortality continues to be associated with age ><span class="elsevierStyleHsp" style=""></span>2, as Murphy et al.<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">21</span></a> report, due to chronic right ventricular hypertrophy, cyanosis and polycythaemia on cardiac structure and function.</p><p id="par0130" class="elsevierStylePara elsevierViewall">Gatzoulis et al.<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">22</span></a> report that right ventricular hypertrophy starts after birth, increases with age, and becomes irreversible towards the age of 4. This hypertrophy contributes to interstitial fibrosis and the need for extensive muscle resection, with a potential risk of ventricular arrhythmias and ventricular dysfunction.<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">23</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">The presence of annular hypoplasia and pulmonary branches contraindicates primary repair, initial palliation being preferred with systemic-to-pulmonary shunt.<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">23</span></a> Hypoplasia of the pulmonary branches reflects an absence of blood flow and systemic-to-pulmonary shunt is indicated to encourage growth.<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">23,24</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Vobecky et al.<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">25</span></a> described their experience in 141 children palliated with modified Blalock-Taussig shunt, which they reported failed in 36 cases, with pulmonary arterioplasty during the repair of 10 cases, and 90% survival at 5 years.<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">18,26</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">In our study there were 5 cases of palliation with modified Blalock-Taussig shunt, growth and no distortion of the branches were seen, 90% functionality at the time of the total repair, with one case of failure of the shunt, without influencing the outcomes of the subsequent surgery, which coincide with those of Fraser et al.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">11</span></a> and Pozzi et al.<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">27</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">The criteria for immediate reoperation, described by Fraser et al.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">11</span></a> were: right ventricular/left ventricular pressure<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>two-thirds systemic pressure, residual interventricular communication with haemodynamic repercussions, residual obstruction of the right ventricular outflow tract, and severe tricuspid insufficiency.</p><p id="par0155" class="elsevierStylePara elsevierViewall">Correction with transannular patch was performed in 80%, as reported by Seddio et al.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">8</span></a>, 70% reported by Pigula et al.<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">19</span></a>, 54.2% by He et al.,<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">15</span></a> 41.5% by d’Udekem et al.,<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">28</span></a> and in 35% by Mesquita et al.<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">29</span></a> The European Association for Cardio-Thoracic Surgery,<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">20</span></a> and van Dongen et al.<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">30</span></a> report repair with transannular patch as the most frequently used technique (57% of their cases), while, in their series, Voges<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">31</span></a> and Tirilomis et al.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">6</span></a> report its use in 27% of their cases.</p><p id="par0160" class="elsevierStylePara elsevierViewall">During our series’ 75 months follow-up, pulmonary valve insufficiency was the most common cause of morbidity (61%). Yoo et al.<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">32</span></a> report that patients corrected with restrictive physiology (mean residual gradient of right ventricular outflow tract 34<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>mmHg) have smaller right ventricles, less prolonged QRS, reduced adverse affects of chronic pulmonary insufficiency, better tolerance to exercise, and a reduction in pulmonary valve replacement.<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">29,31,33</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">Severe ventricular insufficiency can precede symptoms; these patients should be considered for pulmonary valve replacement before it becomes irreversible. The following are determinants for pulmonary valve replacement: deteriorated functional class, reduced tolerance to exercise; QRS prolongation<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>180<span class="elsevierStyleHsp" style=""></span>ms observed on ECG, echocardiographic evidence of severe pulmonary insufficiency, dilatation and right ventricular dysfunction.<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">6,17,29,33,34</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Follow up of the patients at 30 years showed survival rates of over 91% at 5 years follow-up,<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">8</span></a> and 89% from 10 to 15 years.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">9</span></a> When the patients did not require reoperation due to any cause, survival at 5 years was 70%<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">8</span></a> and 96% at 20 years.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">9</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">In our institution, we showed a 100% survival rate at 10 years from the initial correction of tetralogy of Fallot with transannular patch, which suggests that primary repair with transannular patch can be undertaken safely and effectively.</p><p id="par0180" class="elsevierStylePara elsevierViewall">Despite the long-term survival, and the excellent quality of life that these patients achieve after total correction of Fallot tetralogy, progressive right ventricular dysfunction does occur, therefore none of these patients can be considered to be cured, even asymptomatic patients, and all of them require continuous follow-up; only thus will it be possible to choose the optimal time for pulmonary valve replacement.</p><p id="par0185" class="elsevierStylePara elsevierViewall">The goal of treatment should include: the prevention of long-term complications, and the reduced probability of early and late reoperation, and good neurological and functional development to enable a satisfactory quality of life.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conclusions</span><p id="par0190" class="elsevierStylePara elsevierViewall">Fortunately, advances in medico-surgical strategies have ensured that the morbidity and mortality rates for children born with Fallot tetralogy are significantly lower in the current era compared to a few decades ago.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflict of interests</span><p id="par0195" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres591704" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec607264" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres591703" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec607265" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and methods" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Late morbidity and mortality" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Surgical technique" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Statistical analysis" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Ethical considerations" ] ] ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0045" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflict of interests" ] 10 => array:2 [ "identificador" => "xack199027" "titulo" => "Acknowledgement" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-12-03" "fechaAceptado" => "2015-05-14" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec607264" "palabras" => array:3 [ 0 => "Fallot tetralogy" 1 => "Transannular patch" 2 => "Repair" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec607265" "palabras" => array:3 [ 0 => "Tetralogía de Fallot" 1 => "Reparación quirúrgica" 2 => "Parche transanular" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Primary repair of Fallot tetralogy has been performed successfully for the last 45 years. It has low surgical mortality (<<span class="elsevierStyleHsp" style=""></span>5%), with excellent long-term results. However, there are delayed adverse effects: progressive right ventricular dilation and dysfunction, arrhythmia, and sudden death. In our centre, Fallot tetralogy is the most common form of cyanotic congenital heart disease (including transannular patch) and accounts for 7.5% of all cardiovascular surgical procedures. The mid-term follow-up results are reported.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Case series. The study included patients who had complete repair of Fallot tetralogy with transannular patch from January 2000 to December 2009. An analysis was performed on the clinical variables, morbidity and mortality.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">There were 52 patients in the study, with mean age 4<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2 years. Perioperative mortality in 6 patients, with 5 associated with residual right ventricular obstruction and, 1 associated with further surgery. The survival rate was 88% (46) patients, with a follow-up 75<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>26 months. Late morbidity occurred in 14, due to right ventricular dysfunction in 11, recurrent distal obstruction in 2, and residual ventricular septal defect in 1. Associated risk factors were severe pulmonary insufficiency (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.001); QRS<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>160<span class="elsevierStyleHsp" style=""></span>ms, (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.001); cardiothoracic<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>0.60 index (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.048), and tricuspid regurgitation (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.001).</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">There was reasonable long-term survival and excellent quality of life after total correction of Fallot tetralogy; however, progressive right ventricular dysfunction requires continuous monitoring, as well as the choice of optimal timing of pulmonary valve replacement.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La reparación quirúrgica de la tetralogía de Fallot se ha realizado exitosamente en los últimos 45 años, con mortalidad inferior al 5% y con resultados satisfactorios a largo plazo; sin embargo, existen efectos adversos tardíos como: insuficiencia progresiva ventricular derecha, arritmias y muerte súbita. En el Hospital Infantil de México es la cardiopatía cianógena más frecuente y su corrección quirúrgica (incluido el parche transanular) corresponde al 7.5% de toda la cirugía cardiaca. El propósito de este informe es reportar el seguimiento a 6 años en niños tratados en esta institución.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Serie de casos. Se incluyeron pacientes intervenidos de corrección total de tetralogía de Fallot con parche transanular entre enero de 2000 a diciembre de 2009. Se analizan variables clínicas, morbilidad y mortalidad.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 52 pacientes. Edad 4<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2 años. Mortalidad perioperatoria 6, asociada a obstrucción residual ventricular derecha 5 y, reoperación por isquemia miocárdica en 1. Sobrevida 46 (88%) pacientes, seguimiento 75<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>26 meses. La morbilidad tardía se presentó en 14, debido a insuficiencia ventricular derecha en 11, obstrucción recurrente distal 2 y comunicación interventricular residual uno. Factores de riesgo asociados de insuficiencia ventricular derecha: insuficiencia pulmonar grave (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.001); complejo QRS<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>160<span class="elsevierStyleHsp" style=""></span>ms (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.001); índice cardiotorácico<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>0.60 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.048) e insuficiencia tricuspídea (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.001).</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Encontramos una sobrevida razonable a largo plazo y calidad de vida excelente, posterior a la corrección total de tetralogía de Fallot; sin embargo, la insuficiencia progresiva ventricular derecha obliga a un continuo seguimiento para elegir el momento óptimo de reemplazo valvular pulmonar.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Galicia-Tornell M, Reyes-López A, Ruíz-González S, Bolio-Cerdán A, González-Ojeda A, Fuentes-Orozco C. Tratamiento de la tetralogía de Fallot con parche transanular. Seguimiento a 6 años. Cirugía y Cirujanos. 2015;83:478–484.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1067 "Ancho" => 850 "Tamanyo" => 183191 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Placing a transannular patch with autologous pericardium (treated with 0.6% glutaraldehyde for 10<span class="elsevierStyleHsp" style=""></span>min and washed with saline solution) with the smooth portion facing pulmonary flow.</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" => 1210 "Ancho" => 850 "Tamanyo" => 237680 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Transatrial approach for closure of interventricular communication.</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" => 1213 "Ancho" => 850 "Tamanyo" => 226096 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Closure of interventricular communication.</p>" ] ] 3 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">95% CI, 95% confidence interval; CTI, cardiothoracic index; PI, pulmonary insufficiency; TI, tricuspid insufficiency; OR, odds ratio.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">With severe ventricular dilatation \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Without severe ventricular dilatation \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> value \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">OR (CI 95%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Severe PI grave \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.001 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.55 (0.39–0.77) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Moderate PI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">QRS complex<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>160 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.001 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15.9 (4–61.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">QRS<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>160 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">CTI<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.048 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.67 (0.39–18.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">CTI<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mild TI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.001 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.36 (0.005–0.25) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Moderate and severe TI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab966983.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Univariate analysis of risk factors for the development of severe ventricular dilatation.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:34 [ 0 => array:3 [ "identificador" => "bib0175" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hot topics in tetralogy of Fallot" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. 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| Year/Month | Html | Total | |
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| 2024 October | 54 | 4 | 58 |
| 2024 September | 121 | 11 | 132 |
| 2024 August | 87 | 2 | 89 |
| 2024 July | 87 | 5 | 92 |
| 2024 June | 83 | 8 | 91 |
| 2024 May | 133 | 14 | 147 |
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| 2024 March | 105 | 13 | 118 |
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| 2023 December | 115 | 14 | 129 |
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| 2023 October | 166 | 37 | 203 |
| 2023 September | 84 | 14 | 98 |
| 2023 August | 108 | 6 | 114 |
| 2023 July | 96 | 17 | 113 |
| 2023 June | 103 | 6 | 109 |
| 2023 May | 163 | 3 | 166 |
| 2023 April | 133 | 7 | 140 |
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| 2022 December | 71 | 12 | 83 |
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| 2021 December | 103 | 21 | 124 |
| 2021 November | 116 | 19 | 135 |
| 2021 October | 101 | 17 | 118 |
| 2021 September | 101 | 17 | 118 |
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| 2021 July | 92 | 17 | 109 |
| 2021 June | 94 | 10 | 104 |
| 2021 May | 110 | 20 | 130 |
| 2021 April | 285 | 29 | 314 |
| 2021 March | 185 | 18 | 203 |
| 2021 February | 138 | 22 | 160 |
| 2021 January | 141 | 24 | 165 |
| 2020 December | 130 | 19 | 149 |
| 2020 November | 106 | 13 | 119 |
| 2020 October | 86 | 10 | 96 |
| 2020 September | 80 | 16 | 96 |
| 2020 August | 84 | 13 | 97 |
| 2020 July | 83 | 14 | 97 |
| 2020 June | 104 | 13 | 117 |
| 2020 May | 93 | 13 | 106 |
| 2020 April | 76 | 12 | 88 |
| 2020 March | 118 | 10 | 128 |
| 2020 February | 88 | 9 | 97 |
| 2020 January | 64 | 9 | 73 |
| 2019 December | 48 | 8 | 56 |
| 2019 November | 54 | 9 | 63 |
| 2019 October | 63 | 6 | 69 |
| 2019 September | 69 | 12 | 81 |
| 2019 August | 61 | 12 | 73 |
| 2019 July | 64 | 16 | 80 |
| 2019 June | 121 | 6 | 127 |
| 2019 May | 244 | 15 | 259 |
| 2019 April | 89 | 11 | 100 |
| 2019 March | 20 | 12 | 32 |
| 2019 February | 28 | 5 | 33 |
| 2019 January | 16 | 3 | 19 |
| 2018 December | 22 | 6 | 28 |
| 2018 November | 31 | 6 | 37 |
| 2018 October | 19 | 8 | 27 |
| 2018 September | 7 | 3 | 10 |
| 2018 August | 7 | 2 | 9 |
| 2018 July | 14 | 4 | 18 |
| 2018 June | 4 | 1 | 5 |
| 2018 May | 18 | 0 | 18 |
| 2018 April | 16 | 1 | 17 |
| 2018 March | 6 | 1 | 7 |
| 2018 February | 11 | 2 | 13 |
| 2018 January | 6 | 0 | 6 |
| 2017 December | 16 | 3 | 19 |
| 2017 November | 11 | 1 | 12 |
| 2017 October | 13 | 5 | 18 |
| 2017 September | 9 | 0 | 9 |
| 2017 August | 12 | 5 | 17 |
| 2017 July | 19 | 7 | 26 |
| 2017 June | 29 | 4 | 33 |
| 2017 May | 23 | 13 | 36 |
| 2017 April | 18 | 33 | 51 |
| 2017 March | 27 | 42 | 69 |
| 2017 February | 28 | 2 | 30 |
| 2017 January | 33 | 2 | 35 |
| 2016 December | 29 | 4 | 33 |
| 2016 November | 15 | 6 | 21 |
| 2016 October | 26 | 4 | 30 |
| 2016 September | 42 | 4 | 46 |
| 2016 August | 20 | 2 | 22 |
| 2016 July | 12 | 2 | 14 |
| 2016 June | 44 | 11 | 55 |
| 2016 May | 36 | 17 | 53 |
| 2016 April | 26 | 13 | 39 |
| 2016 March | 55 | 14 | 69 |
| 2016 February | 56 | 27 | 83 |
| 2016 January | 34 | 22 | 56 |
| 2015 December | 8 | 7 | 15 |
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