Fig 6. Proposed schematic of progressive RV dysfunction leading to dynamic changes in circulating miRNA expression.

Progressive RV enlargement likely leads to systemic responses to incite global transcriptional changes within circulating cells which may subsequently incite changes in myocardial tissue, activating pathways including cell cycle, fatty acid biosynthesis, and TGF-β, while inhibiting HIF1. Red arrows denote the most dysregulated pathways.