Vascular wall remodeling in pulmonary hypertension is contributed to by an aberration in the normal balance between proliferation and apoptosis of smooth muscle. We observed that endothelin (ET)-1 is a critical mediator of vascular remodeling in neonatal rats chronically exposed to 60% O 2 , but has no direct proliferative effects on cultured neonatal rat pulmonary artery smooth muscle cells (PASMCs). These findings led us to hypothesize that ET-1 may modulate remodeling by inhibiting apoptosis of smooth muscle. ET-1 (0.1 M) was found to significantly attenuate both Paclitaxel-and serum deprivation-induced PASMC apoptosis, likely through stimulation of the ET A receptor (ET A R). ET-1 also prevented Paclitaxel-induced up-regulation of pro-apoptotic Bax and cleaved (activated) caspase-3. In rat pups exposed from birth to 60% O 2 for 7 d, arterial wall expression of Bax was decreased and expression of both ET A R and anti-apoptotic Bcl-xL were increased. Furthermore, increased numbers of TUNEL-positive cells were evident in the walls of pulmonary arteries from 60% O 2 -exposed animals treated with a combined ET receptor antagonist, SB217242, relative to air-exposed and vehicle-treated groups. Together, these findings suggest that ET-1 mediates remodeling of neonatal rat pulmonary arteries by inhibiting smooth muscle apoptosis. (Pediatr Res 60: 245-251, 2006) P ulmonary hypertension is a frequently observed complication of critically ill newborn infants that causes considerable mortality and long-term morbidity (1). The pathogenesis of pulmonary hypertension is believed to relate to two phenomena that contribute to increased pulmonary arterial resistance and pressure: sustained vasoconstriction and remodeling of resistance arteries. Arterial wall remodeling is contributed to, in major part, by hyperplasia of the medial smooth muscle layer (2). Remodeling increases vascular resistance through luminal encroachment and enhanced contractile potential (3,4), which limits the effectiveness of established vasodilator therapies. Moreover, given that alveolar and vascular development appear to be interdependent processes, pulmonary hypertension in the newborn may also be associated with inhibition of lung growth and alveolar development (5,6). A greater understanding of the mechanisms leading to pulmonary vascular remodeling in the newborn therefore has the potential to greatly improve outcomes.An aberration in the normal balance between proliferation and apoptosis of smooth muscle contributes to vascular remodeling in pulmonary hypertension (7-9). Studies utilizing various endothelin (ET) receptor antagonists have confirmed that the polypeptide, ET-1, is critical to the pathogenesis of vascular remodeling in both adult and newborn (10,11) rodent models of chronic pulmonary hypertension. A major role for ET-1 in pulmonary hypertension of human newborns is also suggested by observational studies (12,13). In addition to being the most potent vasoconstrictor described to date, ET-1 has been reported to directly modul...