Endothelin receptor antagonists are used to treat idiopathic pulmonary arterial hypertension (IPAH), but human pulmonary arterial endothelin receptor expression is not well defined. We hypothesised that disease and treatment would modify normal receptor distribution in pulmonary resistance arteries of children.Using immunohistochemistry and semiquantitative analysis, we investigated endothelin receptor subtypes A and B (ETA and ETB, respectively), and endothelial nitric oxide synthase (eNOS) expression in peripheral pulmonary arteries of tissue from untreated children with IPAH (n57), following extended combined bosentan and epoprostenol therapy (n55) and from normal subjects (n55).Clinical, haemodynamic and pathological abnormalities were severe and advanced in all IPAH cases. ETA was detected in pulmonary arterial endothelial cells of all normal and diseased tissue and cultured cells. Endothelial ETA, ETB and eNOS expression was reduced in patent, plexiform and dilatation lesions of untreated cases, but in treated cases, ETA and ETB were normal and eNOS increased. In smooth muscle, ETA expression was reduced in treated cases but ETB expression increased in all arteries of both treated and untreated cases.In summary, ETA is expressed on human pulmonary arterial endothelium. In IPAH, combination treatment with bosentan and epoprostenol had a more marked influence on endothelin receptor expression of endothelial than smooth muscle cells.KEYWORDS: Endothelin receptor antagonists, endothelin receptor A and B, endothelium, paediatric idiopathic pulmonary arterial hypertension, peripheral pulmonary arteries I diopathic pulmonary arterial hypertension (IPAH) is a rare, incurable disorder occurring in both children and adults with a normally formed heart, characterised by irreversible occlusion of small intra-acinar pulmonary resistance arteries with development of plexiform lesions resulting in a sustained increase in pulmonary arterial pressure [1]. Death results from right heart failure. Treatment with prostacyclin, endothelin receptor antagonists and phosphodiesterase inhibitors aims to promote dilatation and reparative remodelling of the pulmonary arteries, and has improved survival and quality of life but is not curative [1]. The only therapeutic option for endstage disease is lung transplantation.The endothelin ET-1 is a potent vasoconstrictor and smooth muscle cell mitogen [2] that is important in the pathobiology of pulmonary arterial hypertension [3]. In humans with IPAH, plasma endothelin levels are elevated [4], endothelin-converting enzyme activity is enhanced [5] and lung expression of endothelin is increased [6]. Its action is mediated principally by two receptors, ETA and ETB [7]. Both mediate vasoconstriction of human smooth muscle cells whilst endothelial ETB receptors mediate vasorelaxation via endothelial nitric oxide synthase (eNOS) [8]. In experimentally induced pulmonary hypertension, the endothelin receptor antagonists diminish or abrogate endothelin-induced smooth muscle cell contract...