As an example, in heart failure the association with LV dominance appears to be multifactorial with one of the leading factors being the activation of the renin–angiotensin–aldosterone system which provokes significant LV remodelling.24 Left ventricular dominant asymmetry was strongly associated with the development of AF with that being elucidated by LV dominance inducing left atrial remodelling driven by atrial fibrosis.25,26 The molecular and cellular mechanisms that connect ventricular asymmetry to cardiac remodelling and disease development warrant further investigation. This evidence concerns the gene REN and heart failure.