Left ventricular dyssynchrony predicts response and prognosis after cardiac resynchronization therapy

OBJECTIVES This study was designed to predict the response and prognosis after cardiac resynchronization therapy (CRT) in patients with end-stage heart failure (HF). BACKGROUND Cardiac resynchronization therapy improves HF symptoms, exercise capacity, and left ventricular (LV) function. Because not all patients respond, preimplantation identification of responders is needed. In the present study, response to CRT was predicted by the presence of LV dyssynchrony assessed by tissue Doppler imaging. Moreover, the prognostic value of LV dyssynchrony in patients undergoing CRT was assessed. METHODS Eighty-five patients with end-stage HF, QRS duration >120 ins, and left bundle-branch block were evaluated by tissue Doppler imaging before CRT. At baseline and six months follow-up, New York Heart Association functional class, quality of life and 6-min walking distance, LV volumes, and LV ejection fraction were determined. Events (death, hospitalization for decompensated HF) were obtained during one-year follow-up. RESULTS Responders (74%) and nonresponders (26%) had comparable baseline characteristics, except for a larger dyssynchrony in responders (87 +/- 49 ms vs. 35 +/- 20 ms, p < 0.01). Receiver-operator characteristic curve analysis demonstrated that an optimal cutoff value of 65 ms for LV dyssynchrony yielded a sensitivity and specificity of 80% to predict clinical improvement and of 92% to predict LV reverse remodeling. Patients with dyssynchrony :65 ms had an excellent prognosis (6% event rate) after CRT as compared with a 50% event rate in patients with dyssynchrony <65 ins (p < 0.001). CONCLUSIONS Patients with LV dyssynchrony greater than or equal to65 ms respond to CRT and have an excellent prognosis after CRT. (C) 2004 by the American College of Cardiology Foundation.

Accuracy of Goldmann, ocular response analyser, Pascal and TonoPen XL tonometry in keratoconic and normal eyes

Aim: The aim of this study was to evaluate the practicality and accuracy of tonometers used in routine clinical practice for established keratoconus (KC). Methods: This was a prospective study of 118 normal and 76 keratoconic eyes where intraocular pressure (IOP) was measured in random order using the Goldman applanation tonometer (GAT), Pascal dynamic contour tonometer (DCT), Reichert ocular response analyser (ORA) and TonoPen XL tonometer. Corneal hysteresis (CH) and corneal resistance factor (CRF), as calculated by the ORA, were recorded. Central corneal thickness (CCT) was measured using an ultrasound pachymeter. Results: The difference in IOP values between instruments was highly significant in both study groups (p<0.001). All other IOP measures were significantly higher than those for GAT, except for the Goldmann-correlated IOP (average of the two applanation pressure points) (IOPg) as measured by ORA in the control group and the CH-corrected IOP (corneal-compensated IOP value) (IOPcc) measures in the KC group. CCT, CH and CRF were significantly less in the KC group (p<0.001). Apart from the DCT, all techniques tended to measure IOP higher in eyes with thicker corneas. Conclusion: The DCT and the ORA are currently the most appropriate tonometers to use in KC for the measurement of IOPcc. Corneal factors such as CH and CRT may be of more importance than CCT in causing inaccuracies in applanation tonometry techniques.

Effect of initial retinal thickness on outcome of intravitreal bevacizumab therapy for diabetic macular edema

Purpose: To investigate whether eyes with diabetic macular edema (DME) and central retinal thickness (CRT) >400 μm had better visual and anatomical outcomes compared to eyes with a CRT <400 μm when treated with intravitreal bevacizumab in a real-world setting. Patients and methods: Patients undergoing intravitreal bevacizumab therapy for DME were identified from the departmental database of a tertiary referral unit. Following the initial injection, a retreatment was performed for any persistent macular edema, unless there had been no previous response to repeated doses. Recorded parameters included visual acuity, CRT on optical coherence tomography (spectral domain optical coherence tomography [SD-OCT]), and SD-OCT characteristics. Comparisons were made between data at baseline and 12 months after the first injection, and differences were tested for statistical significance using the Student's t-test. Results: In all, 175 eyes of 142 patients were analyzed. Patients in group 2 (CRT >400 μm) had significantly more injections than group 1 (CRT <400 μm) (4.0 versus 3.3; P=0.003). Both groups had similar numbers of eyes with preexisting epiretinal membrane and/or vitreomacular traction at baseline. The reduction in CRT was significantly greater in group 2 when compared to group 1 (P<0.0001). In terms of visual gain between baseline and month 12, each gained significantly by a mean of 0.12 logarithm of the minimum angle of resolution units (P=0.0001), but there was no difference between groups 1 and 2 (P=0.99). Conclusion: These results do not support a 400 μm baseline CRT cut-off for treating DME with bevacizumab, in contrast to published data on ranibizumab. Our results also indicate that patients with a thicker CRT require more bevacizumab injections, making treatment less cost-effective for these patients. Our results could be used by practitioners to support the use of bevacizumab in DME without applying a CRT cut-off. © 2014 Mushtaq et al.

Defining response to anti-VEGF therapies in neovascular AMD

The introduction of anti-vascular endothelial growth factor (anti-VEGF) has made significant impact on the reduction of the visual loss due to neovascular age-related macular degeneration (n-AMD). There are significant inter-individual differences in response to an anti-VEGF agent, made more complex by the availability of multiple anti-VEGF agents with different molecular configurations. The response to anti-VEGF therapy have been found to be dependent on a variety of factors including patient’s age, lesion characteristics, lesion duration, baseline visual acuity (VA) and the presence of particular genotype risk alleles. Furthermore, a proportion of eyes with n-AMD show a decline in acuity or morphology, despite therapy or require very frequent re-treatment. There is currently no consensus as to how to classify optimal response, or lack of it, with these therapies. There is, in particular, confusion over terms such as ‘responder status’ after treatment for n-AMD, ‘tachyphylaxis’ and ‘recalcitrant’ n-AMD. This document aims to provide a consensus on definition/categorisation of the response of n-AMD to anti-VEGF therapies and on the time points at which response to treatment should be determined. Primary response is best determined at 1 month following the last initiation dose, while maintained treatment (secondary) response is determined any time after the 4th visit. In a particular eye, secondary responses do not mirror and cannot be predicted from that in the primary phase. Morphological and functional responses to anti-VEGF treatments, do not necessarily correlate, and may be dissociated in an individual eye. Furthermore, there is a ceiling effect that can negate the currently used functional metrics such as >5 letters improvement when the baseline VA is good (ETDRS>70 letters). It is therefore important to use a combination of both the parameters in determining the response.The following are proposed definitions: optimal (good) response is defined as when there is resolution of fluid (intraretinal fluid; IRF, subretinal fluid; SRF and retinal thickening), and/or improvement of >5 letters, subject to the ceiling effect of good starting VA. Poor response is defined as <25% reduction from the baseline in the central retinal thickness (CRT), with persistent or new IRF, SRF or minimal or change in VA (that is, change in VA of 0+4 letters). Non-response is defined as an increase in fluid (IRF, SRF and CRT), or increasing haemorrhage compared with the baseline and/or loss of >5 letters compared with the baseline or best corrected vision subsequently. Poor or non-response to anti-VEGF may be due to clinical factors including suboptimal dosing than that required by a particular patient, increased dosing intervals, treatment initiation when disease is already at an advanced or chronic stage), cellular mechanisms, lesion type, genetic variation and potential tachyphylaxis); non-clinical factors including poor access to clinics or delayed appointments may also result in poor treatment outcomes. In eyes classified as good responders, treatment should be continued with the same agent when disease activity is present or reactivation occurs following temporary dose holding. In eyes that show partial response, treatment may be continued, although re-evaluation with further imaging may be required to exclude confounding factors. Where there is persistent, unchanging accumulated fluid following three consecutive injections at monthly intervals, treatment may be withheld temporarily, but recommenced with the same or alternative anti-VEGF if the fluid subsequently increases (lesion considered active). Poor or non-response to anti-VEGF treatments requires re-evaluation of diagnosis and if necessary switch to alternative therapies including other anti-VEGF agents and/or with photodynamic therapy (PDT). Idiopathic polypoidal choroidopathy may require treatment with PDT monotherapy or combination with anti-VEGF. A committee comprised of retinal specialists with experience of managing patients with n-AMD similar to that which developed the Royal College of Ophthalmologists Guidelines to Ranibizumab was assembled. Individual aspects of the guidelines were proposed by the committee lead (WMA) based on relevant reference to published evidence base following a search of Medline and circulated to all committee members for discussion before approval or modification. Each draft was modified according to feedback from committee members until unanimous approval was obtained in the final draft. A system for categorising the range of responsiveness of n-AMD lesions to anti-VEGF therapy is proposed. The proposal is based primarily on morphological criteria but functional criteria have been included. Recommendations have been made on when to consider discontinuation of therapy either because of success or futility. These guidelines should help clinical decision-making and may prevent over and/or undertreatment with anti-VEGF therapy.

Ranibizumab 0.5 mg for diabetic macular edema with bimonthly monitoring after a phase of initial treatment:18-month, multicenter, phase IIIB RELIGHT study

Abstract PURPOSE: To evaluate ranibizumab 0.5 mg using bimonthly monitoring and individualized re-treatment after monthly follow-up for 6 months in patients with visual impairment due to diabetic macular edema (DME). DESIGN: A phase IIIb, 18-month, prospective, open-label, multicenter, single-arm study in the United Kingdom. PARTICIPANTS: Participants (N = 109) with visual impairment due to DME. METHODS: Participants received 3 initial monthly ranibizumab 0.5 mg injections (day 0 to month 2), followed by individualized best-corrected visual acuity (BCVA) and optical coherence tomography-guided re-treatment with monthly (months 3-5) and subsequent bimonthly follow-up (months 6-18). Laser was allowed after month 6. MAIN OUTCOME MEASURES: Mean change in BCVA from baseline to month 12 (primary end point), mean change in BCVA and central retinal thickness (CRT) from baseline to month 18, gain of ≥10 and ≥15 letters, treatment exposure, and incidence of adverse events over 18 months. RESULTS: Of 109 participants, 100 (91.7%) and 99 (90.8%) completed the 12 and 18 months of the study, respectively. The mean age was 63.7 years, the mean duration of DME was 40 months, and 77.1% of the participants had received prior laser treatment (study eye). At baseline, mean BCVA was 62.9 letters, 20% of patients had a baseline BCVA of >73 letters, and mean baseline CRT was 418.1 μm, with 32% of patients having a baseline CRT <300 μm. The mean change in BCVA from baseline to month 6 was +6.6 letters (95% confidence interval [CI], 4.9-8.3), and after institution of bimonthly treatment the mean change in BCVA at month 12 was +4.8 letters (95% CI, 2.9-6.7; P < 0.001) and +6.5 letters (95% CI, 4.2-8.8) at month 18. The proportion of participants gaining ≥10 and ≥15 letters was 24.8% and 13.8% at month 12 and 34.9% and 19.3% at month 18, respectively. Participants received a mean of 6.8 and 8.5 injections over 12 and 18 months, respectively. No new ocular or nonocular safety findings were observed during the study. CONCLUSIONS: The BCVA gain achieved in the initial 6-month treatment period was maintained with an additional 12 months of bimonthly ranibizumab PRN treatment.

Arsène Darmesteter : professeur à la Faculté des lettres de Paris ; né à Château-Salins (Meurthe), le 5 janvier 1846 ; mort à Paris le 16 novembre 1888

[Zadoc Kahn ...]

Pollen profile and age determination for sediment core M72/5_619-1 (22-GC3)

Sediments from the Black Sea, a region historically dominated by forests and steppe landscapes, are a valuable source of detailed information on the changes in regional terrestrial and aquatic environments at decadal to millennial scales. Here we present multi-proxy environmental records (pollen, dinoflagellate cysts, Ca, Ti and oxygen isotope data) from the uppermost 305 cm of the core 22-GC3 (42°13.53' N, 36°29.55' E) collected from a water depth of 838 m in the southern part of the Black Sea in 2007. The records span the last ~ 18 kyr (all ages are given in cal kyr BP). The pollen data reveal the dominance of the Artemisia-steppe in the region, suggesting rather dry/cold environments ~ 18-14.5 kyr BP. Warming/humidity increase during melt-water pulses (~ 16.1-14.5 kyr BP), indicated by d18O records from the 22-GC3 core sediment and from the Sofular Cave stalagmite, is expressed in more negative d13C values from the Sofular Cave, usually interpreted as the spreading of C3 plants. The records representing the interstadial complex (~ 14.5-12.9 kyr BP) show an increase in temperature and moisture, indicated by forest development, increased primary productivity and reduced surface run-off, whereas the switch from primary terrigenous to primary authigenic Ca origin occurs ~ 500 yr later. The Younger Dryas cooling is clearly demonstrated by more negative d13C values from the Sofular Cave and a reduction of pines. The early Holocene (11.7-8.5 kyr BP) interval reveals relatively dry conditions compared to the mostly moist and warm middle Holocene (8.5-5 kyr BP), which is characterized by the establishment of the species-rich warm mixed and temperate deciduous forests in the low elevation belt, temperate deciduous beech-hornbeam forests in the middle and cool conifer forest in upper mountain belt. The border between the early and middle Holocene in the vegetation records coincides with the opening of the Mediterranean corridor at ~ 8.3 kyr BP, as indicated by a marked change in the dinocyst assemblages and in the sediment lithology. Changes in the pollen assemblages indicate a reduction in forest cover after ~ 5 kyr BP, which was likely caused by increased anthropogenic pressure on the regional vegetation.

Flammability Standards – A Major Role in Flame Retardant Exposure? Televisions as a case study.

Flame retardants (FRs) are added to materials to enhance the fire safety level of readily combustible polymers. Although they have been purported to aid in preventing fires in some cases, they have also become a significant cause for concern given the vast data on environmental persistence and human and animal adverse health effects. Evidence since the 1980s has shown that Canadian, American and Europeans have detectable levels of FRs in their bodies. North Americans in particular have high levels of these chemicals due to stringent flammability standards and the higher use of polybrominated diphenyl ethers (PBDEs) in North America as opposed to Europe. FRs have been detected in household dust and some evidence suggests that TVs could be a significant source of exposure to FRs. It is imperative to re-visit the flammability standard (UL94V) that allows for FR use in TVs plastic materials by providing a risk versus benefit analysis to determine if this standard provides a fire safety benefit and if it plays a major role in FR exposure. This report first examined the history of televisions and the progression to the UL94V flammability test standard to understand why FRs were first added to polymers used in the manufacturing of TVs. It has been demonstrated to be due to fire hazards resulting from the use of plastic materials in cathode-ray tube (CRT) TVs that had an “instant-on” feature and high voltage and operating temperatures. In providing a risk versus benefit analysis, this paper presents the argument that 1) by providing a market survey the current flammability test standard (UL94V) is outdated and lacks relevance to current technology as flat, thin, energy efficient Liquid Crystal Displays (LCDs) dominate over traditionally used heavy, bulky and energy-intensive CRTs; 2) FRs do not impart fire safety benefits considering that there is a lack of valid fire safety concern, such as reduced internal and external ignition and fire hazard, and a lack of valid fire data and hazard for television fires in general and finally; 3) the standard is overly stringent as it does not consider the risk due to exposure to FRs in household dust due to the proliferation and greater use of televisions in households. Therefore, this report argues that the UL94V standard has become trapped in history and needs to be updated as it may play a major role in FR exposure.

Can cognitive skills and risk aversion explain inconsistent choices?: an experiment

Estudia la coherencia de las preferencias de riesgo entre universitarios en un país en vías de desarrollo. El diseño permite obtener la coherencia a nivel individual, en el que cada sujeto selecciona sus opciones preferidas de dos diferentes, pero relacionadas tareas de obtención de riesgo. En la primera tarea, los sujetos eligen una opción entre seis alternativas, descartando así la inconsistencia. La segunda tarea, es una transformación de la primera, que está destinada a examinar si la elección en la primera tarea también se revela como preferida. Al usar estas opciones, se construye medidas de preferencias incoherentes y analiza su correlación con las habilidades cognitivas (medido según Frederick (2005) en Cognitive Reflection Test—CRT scores and students’ GPAs) y las preferencias de riesgo. Se encontró que una puntuación CRT baja y un pobre rendimiento académico son, generalmente buenos predictores de decisiones inconsistentes. Los resultados son contradictorios en términos del papel de la aversión al riesgo.

“Never Give up:” The Strengths and Strategies Used Among Undocumented College Students From Central America to Access and Persist in U.S. Higher Education

The purpose of this study was to identify the strengths and strategies that undocumented college students from Central America used to access and persist in United States higher education. A multiple-case study design was used to conduct in-depth, semi-structured interviews and document collection from ten persons residing in Illinois, Maryland, Ohio, Texas, and Washington. Yosso’s (2005, 2006) community cultural wealth conceptual framework, an analytical and methodological tool, was used to uncover assets used to navigate the higher education system. The findings revealed that participants activated all forms of capital, with cultural capital being the least activated yet necessary, to access and persist in college. Participants also activated most forms of capital together or consecutively in order to attain financial resources, information and social networks that facilitated college access. Participants successfully persisted because they continued to activate forms of capital, displayed a high sense of agency, and managed to sustain college educational goals despite challenges and other external factors. The relationships among forms of capital and federal, state, and institutional policy contexts, which positively influenced both college access and persistence were not illustrated in Yosso’s (2005, 2006) community cultural wealth framework. Therefore, this study presents a modified community cultural wealth framework, which includes these intersections and contexts. In the spirit of Latina/o critical race theory (LatCrit) and critical race theory (CRT), the participants share with other undocumented students suggestions on how to succeed in college. This study can contribute to the growing research of undocumented college students, and develop higher education policy and practice that intentionally consider undocumented college students’ strengths to successfully navigate the institution.

Satisfação dos doentes portadores de CDI e CRT­‐D com seguimento remoto

Introdução: A monitorização remota (MR) apresenta diversas vantagens sendo uma delas o aumento do nível de satisfação dos doentes, utilizada como medida par avaliar os programas de seguimento remoto. Objetivo: Avaliar a satisfação dos doentes portadores de CDI ou CRT-D que realizem consulta de monitorização/seguimento remoto. Metodologia: Estudo observacional, descritivo e analítico com componente transversal. A recolha dos dados foi realizada telefonicamente, através da implementação de um questionário validado e adaptado aos objectivos do presente estudo durante o período compreendido entre 11 de março e 4 de abril de 2014. As questões foram essencialmente de resposta fechada, recaindo sobre a perceção e satisfação dos doente com MR, como nova metodologia de consulta. Resultados: A amostra contou com 54 inquiridos com um tempo médio de MR de 2.57 + 1.63 anos. 50% dos doentes referiram estar satisfeitos e 38.9% muito satisfeitos com a consulta de MR, sendo que 34 (63%) prefere esta consulta. Para além disso, 31.5% classificam a qualidade como sendo melhor do que a consulta presencial, enquanto 51.9% a classifica como de igual qualidade. Quanto ao sentimento de segurança e confiança, estes estão presentes em 94.4% e 88.9% das respostas dos inquiridos, respetivamente. Por fim, 88.9% dos doente continuaria a longo prazo, com a consulta à distância. Conclusão: A maioria dos doentes inquiridos responde estar satisfeita ou muito satisfeita com a consulta de MR. Quando comparada com a consulta presencial, a consulta à distância foi classificada como tendo uma qualidade igual ou superior/melhor. Existe uma enorme aceitação e preferência pelo novo sistema de MR, aliado à consulta presencial.

17-Week Delay Surgery after Chemoradiation in Rectal Cancer with Complete Pathological Response

Neoadjuvant chemoradiation (CRT) followed by curative surgery still remains the standard of care for locally advanced rectal cancer (LARC). The main purpose of this multimodal treatment is to achieve a complete pathological tumor response (ypCR), with better survival. The surgery delay after CRT completion seems to increase tumor response and ypCR rate. Usually, time intervals range from 8 to 12 weeks, but the maximum tumor regression may not be seen in rectal adenocarcinomas until several months after CRT. About this issue, we report a case of a 52-year-old man with LARC treated with neoadjuvant CRT who developed, one month after RT completion, an acute myocardial infarction. The need to increase the interval between CRT and surgery for 17 weeks allowed a curative surgery without morbidity and an unexpected complete tumor response in the resected specimen (given the parameters presented in pelvic magnetic resonance imaging (MRI) performed 11 weeks after radiotherapy completion).

Analysis of personality traits as a risk factor in crash related trauma.

Background: Due to increasing stress, individual personality traits are becoming a significant contributor to CRT (Crash Related Trauma). In the present study, we hypothesized that there will be no difference in personality characteristics of CRT patients and control subjects and there will be no association between trauma and personality characteristics of CRT patients. Method: A total of 119 cases and 112 controls of age >18 years were selected as per criteria decided. After obtaining ethical clearance, patients presenting to the emergency orthopedic unit were included in the study. After primary management all enrolled subjects were assessed by ICD 10 module screening questionnaire and analyzed for nine personality traits, subject to written informed consent. Results: Of all the cases enrolled 82.35% were males. Impulsive personality trait is found in 84.78% (39/46) cases. There were 46 motorcyclists out of 119 cases enrolled. Most of the personality traits showed a statistical significant association (p < 0.0003) with CRT. Conclusion: Majority of CRT victims attending orthopedic emergency unit at trauma center had impulsive and histrionic personality characteristics which accounted for 84.78% and 82.61% cases respectively. These traits showed a statistical significant association with CRT.

Evaluación del efecto antitumoral de una fusoquina compuesta por ip10 y linfotactina en un modelo murino de cáncer de cérvix

El término “fusoquina” se utiliza para denominar a las proteínas de fusión compuestas por dos diferentes citocinas. Las citocinas son una familia de proteínas y glicoproteínas solubles que controlan la activación, proliferación e incluso la muerte celular programada de células del sistema inmune. Debido a su participación natural como inmunomoduladores se ha investigado su importancia en la regulación de microambiente tumoral. Dos de las quimiocinas que se han estudiado son IP10 y linfotactina. En nuestro equipo de trabajo se construyó previamente un vector adenoviral que expresa la fusión de estas quimiocinas. Por lo que el propósito de este trabajo fue evaluar el efecto antitumoral y antiangiogénico de este adenovirus. Para esto se produjeron las partículas virales a gran escala, se purificaron y cuantificaron por el método de punto final en placa. El modelo in vivo que se utilizó fue la cepa de ratón C57BL/6 y la línea tumoral de pulmón TC-1. Para determinar si el Ad-FIL incrementa el efecto antitumoral de la vacuna de DNA CRT/E7, los ratones fueron sensibilizados con ésta vacuna y posteriormente se les administraron los tratamientos Ad-Vacío, Ad-IP10, Ad-LPTN, Ad-IP10 + Ad-LPTN o Ad-FIL. Para le evaluación del efecto antiangiogénico los ratones fueron sacrificados y se obtuvieron los tumores, estos fueron procesados por la técnica histológica y se llevó a cabo una inmunohistoquímica para el marcador de vasos CD31. Finalmente se realizó un ensayo antitumoral empleando las mismas construcciones en un contexto de vacunas de DNA, para esto se emplearon dos grupos de ratones, uno de los grupos de ratones recibieron ambas vacunas de DNA (CRT/E7 + quimiocinas) mientras que el otro grupo de ratones recibieron solamente las quimocinas. La fusoquina FIL compuesta por IP10 y Linfotactina no presentó efecto antitumoral en el modelo estudiado; sin embargo, si presentó un efecto antiangiogénico significativo. Se deberá estudiar esta fusoquina en otros modelos y condiciones para continuar evaluando su efecto biológico, así como su utilidad al administrarla en combinación con otros tratamientos.

Terapia de resincronización cardíaca para sujetos con insuficiencia cardíaca asintomáticos o levemente sintomáticos: Un cambio de paradigma: del rescate a la prevención

Hacia fines de la década de 1990 comenzó a utilizarse con éxito la estimulación cardíaca en ambas cámaras ventriculares (resincronización venticular) como terapia en insuficiencia cardíaca refractaria al tratamiento farmacológico convencional en pacientes con complejo QRS ensanchado. Fue hasta el 2005 que el estudio CARE-HF demostró que la resincronización reducía la mortalidad en forma significativa, incluso sin necesidad de acompañarla de un cardiodesfibrilador implantable (DAI o desfibrilador automático implantable). En forma más reciente, a través de los estudios REVERSE, MADIT-CRT y RAFT, se ha comprobado la utilidad de la terapia de resincronización incluso en individuos con insuficiencia cardíaca poco sintomática, es decir en clase funcional I o II, lo cual constituye un cambio cualitativo y cuantitativo en este tratamiento eléctrico para la insuficiencia cardíaca. Al mismo tiempo se han hecho significativos avances en la selección del paciente considerando la enfermedad de base, el patrón de bloqueo en el electrocardiograma, la duración del complejo QRS, y la presencia o no de fibrilación auricular. Como resultado de esto, la terapia de resincronización ha producido mejoría en la calidad de vida, ha demostrado que favorece el fenómeno de remodelado inverso y que también disminuye la mortalidad en individuos en clase funcional I o II.