Right Ventricular Remodeling in Pulmonary Arterial Hypertension: From Adaptive Compensation to Maladaptive Failure

Pulmonary arterial hypertension (PAH) comprises a group of progressive pulmonary circulatory diseases characterized by a persistent increase in pulmonary vascular resistance. In early-stage PAH, the right heart maintains systolic function via myocardial hypertrophy and structural remodeling. However, with the continuous increase in pulmonary vascular resistance, this adaptive remodeling gradually becomes maladaptive and ultimately leads to right ventricular (RV) dilation, systolic dysfunction, right heart failure, and death. A systematic understanding of the intrinsic mechanism driving RV remodeling in PAH is still lacking. Previous studies have mainly focused on pulmonary vascular remodeling and associated molecular mechanisms, with insufficient attention to the dynamic trajectory of RV adaptation and failure under chronic pressure overload. This review summarizes the latest progress in our understanding of the intrinsic mechanisms underlying RV remodeling in PAH, and discusses emerging approaches for imaging assessment and therapies. By integrating mechanistic research with clinical practice, our aim was to reveal frontier advances and future challenges in RV remodeling of PAH.