Mendelson, J. B.; Sternbach, J.; Kim, M.; Raveendran, R.; Moon, R.; Hartweck, L.; Tollison, W.; Carney, J.; Markowski, T.; Higgins, L.; Prins, S.; Kazmirczak, F.; Prins, K.

Background: Right ventricular dysfunction (RVD) is a robust predictor of mortality in multiple cardiovascular diseases. Currently, it remains unclear whether the severity of RVD corresponds to distinct cellular and molecular alterations, and this has important implications for defining optimal therapeutic targets. To address this knowledge gap, we performed a multi-omic evaluation of pulmonary artery banded (PAB) pigs with differing degrees of RV compromise. Methods: PAB pigs were stratified into mild and severe RVD groups using an RV ejection fraction cutoff of 35%. RV tissue from control, mild RVD, and severe RVD animals was analyzed using single-nucleus RNA sequencing, mitochondrial and cytoplasmic proteomics, and phosphoproteomics. Histological analyses corroborated multi-omic findings. Results: Cardiac MRI revealed progressive structural and functional alterations in mild and severe RVD pigs. snRNAseq demonstrated that advancing RVD was associated with loss of cardiomyocytes, accumulation of efferocytosis-impaired macrophages, and dysregulated endothelial cells and pericytes. Combined transcriptomic and proteomic analyses showed escalating impairments of complex cardiomyocyte metabolism with worsening RVD. RV microvasculature was compromised with severe RVD as there were alterations in endothelial cell/pericyte genetic regulation, co-localization patterns in RV sections, and ectopic cardiomyocyte HIF1 expression. Analysis of both mitochondrial and global proteostasis revealed greater compromise in mitochondrial proteostasis, including downregulation of mitochondrial proteases, chaperones, and ribosomes. Paradoxically, cytoplasmic ribosomes were upregulated in severe RVD. The predicted kinome and phosphatome were uniquely altered in mild RVD as compared to severe RVD. Finally, integration of multi-omic approaches identified insufficient mitochondrial unfolded protein response, impaired macrophage efferocytosis, and activation of the ribotoxic stress response as potential contributors to severe RVD. Conclusions: Our multi-omic analysis defines the cellular and molecular landscape of progressive RVD and nominates druggable pathways that may promote progressive RV dysfunction. Future studies are needed to determine how targeting these pathways influences RV phenotypes.