The down-regulation of acetoacetic acid also in the DCM LV vs RV, and the up and down-regulation of ACSS1 and ACYP1, respectively, also in the ICM LV vs RV, do not strongly support a differential increase of ketone metabolism in the LV relative to the RV in end-stage heart failure as seen in donors but, given the well-understood shift of energy substrates seen in LV-dominant cardiomyopathies, suggests that metabolic remodelling may occur in both ventricles26,29,55. This evidence concerns the gene ACSS1 and familial dilated cardiomyopathy.