Beyond the left ventricle: Right ventricular dysfunction as a critical determinant in type 1 diabetes-related cardiomyopathy

Abstract

Diabetic cardiomyopathy (DCM) has long been considered as a left ventricular (LV) disease with diastolic dysfunction preceding systolic dysfunction in diabetes. However, it is increasingly recognized that the right ventricle (RV) is also affected by diabetes and may be independently responsible for adverse outcomes in diabetic patients with or without LV failure. Yu et al conducted a 30-week longitudinal evaluation of biventricular function and pathology in OVE26 diabetic mice and revealed early diastolic dysfunction preceding systolic decline, suggesting that early LV diastolic impairment precedes the later onset of systolic dysfunction. With age, the animals developed fibrosis, hypertrophy, and pulmonary arterial hypertension in the RV. The purpose of this editorial is to contextualize these findings within the existing literature by highlighting the interplay between cardiac chambers and the vasculature. We also seek to reiterate that DCM is a condition extending beyond left ventricular dysfunction. As the authors note, the right side of the heart may remain "the forgotten ventricle" in diabetic patients. We hope that the mechanisms discussed in this paper will help researchers to understand the pathogenesis of cardiovascular disease in this context and encourage clinicians to be more attentive to the associated clinical symptoms.

Keywords: Type 1 diabetes; Diabetic cardiomyopathy; Right ventricular dysfunction; Left ventricular dysfunction; Pulmonary arterial hypertension; Fibrosis; Cardiac remodeling

Core Tip: Yu et al conducted a rare longitudinal study of right ventricle (RV) and left ventricular function in type 1 diabetes. The left ventricle initially presented with diastolic dysfunction, followed by a decline in systolic function. Then, RV dysfunction emerged concurrently with the onset of pulmonary vascular pathologies and structural cardiac changes. These data align with clinical evidence that, although its onset is delayed, right heart failure independently predicts outcomes in diabetic patients. Recognizing RV failure as a component of diabetic cardiomyopathy is thus crucial, as it can facilitate earlier disease screening of diabetes, guide therapeutic strategies, and advance our understanding of biventricular remodeling.