The importance of right ventricular remodelling in pulmonary arterial hypertension

The major determinant of symptoms and outcome in patients with pulmonary arterial hypertension (PAH) is right ventricle (RV) function and its coupling to the pulmonary circulation. To preserve a suffi-cient cardiac output, the RV adapts to increased afterload by increased contrac-tility (homeometric adaptation) and, when this mechanism becomes exhausted, by increased volumes (heterometric adaptation).Recent evidence 1 has shown that PAH progression is characterised by changes in RV dimension and function (increased volumes and decreased ejection frac-tion), even in apparently stable patients, highlighting the importance of RV in determining the prognosis. The study from Goh and colleagues 2 underscores the relevance of RV remodelling in PAH. The authors analysed a large cohort of 505 patients from the ASPIRE (Assessing the Spectrum of Pulmonary hypertension Identified at a REferral centre) registry. Cardiac magnetic resonance allowed to identify four different RV adaptation clusters according to its volume and mass. Patients with a favourable adaptive remodelling (low volume and low mass) had the best prognosis. Interestingly, these patients showed the highest cardiac index, mixed venous oxygen saturation, RV ejection fraction and RV- pulmonary arterial coupling, the lowest mean pulmonary artery pressure and pulmonary vascular resistance (PVR), and the smallest right atrium area. All these prognostic indicators are associated with better RV function. On the contrary, patients with a maladaptive remodelling (high- volume- low- mass) the worst prognosis. study important clin-ical implications.RV reverse remodelling an excellent long- term survival and quality of life, it by For an reverse