Rationale: Severe pulmonary arterial hypertension (PAH) is characterized by the formation of plexiform lesions and concentric intimal fibrosis in small pulmonary arteries. The origin of cells contributing to these vascular lesions is uncertain. Endogenous endothelial progenitor cells are potential contributors to this process. Objectives: To determine whether progenitors are involved in the pathobiology of PAH. Methods: We performed immunohistochemistry to determine the expression of progenitor cell markers (CD133 and c-Kit) and the major homing signal pathway stromal cell-derived factor-1 and its chemokine receptor (CXCR4) in lung tissue from patients with idiopathic PAH, familial PAH, and PAH associated with congenital heart disease. Two separate flow cytometric methods were employed to determine peripheral blood circulating numbers of angiogenic progenitors. Late-outgrowth progenitor cells were expanded ex vivo from the peripheral blood of patients with mutations in the gene encoding bone morphogenetic protein receptor type II (BMPRII), and functional assays of migration, proliferation, and angiogenesis were undertaken. Measurements and Main Results: There was a striking up-regulation of progenitor cell markers in remodeled arteries from all patients with PAH, specifically in plexiform lesions. These lesions also displayed increased stromal cell-derived factor-1 expression. Circulating angiogenic progenitor numbers in patients with PAH were increased compared with control subjects and functional studies of lateoutgrowth progenitor cells from patients with PAH with BMPRII mutations revealed a hyperproliferative phenotype with impaired ability to form vascular networks. Conclusions: These findings provide evidence of the involvement of progenitor cells in the vascular remodeling associated with PAH. Dysfunction of circulating progenitors in PAH may contribute to this process.
Keywords: pulmonary hypertension; endothelial progenitorSevere pulmonary arterial hypertension (PAH) is a rare but devastating condition with a poor prognosis. The conventional model of pulmonary endothelial dysfunction in PAH includes endothelial cell damage, failure of repair, and compromise of barrier integrity (1). Two types of vascular lesions predominate in small pulmonary arteries: concentric intimal lesions consisting of myofibroblast proliferation and smooth muscle hypertrophy with resultant luminal narrowing, and plexiform lesions characterized by disorganized focal proliferation of endothelial channels (2). The vascular injury has been hypothesized to lead to the emergence of apoptosis-resistant endothelial cell clones, and Lee and coworkers (3) have suggested that plexiform lesions, at least in the idiopathic form of PAH, are monoclonal in origin. The appearance of plexiform lesions is thought to signify a poor prognosis (4), but little is understood about the evolution of these focal areas of neoangiogenesis. Their contribution to increased vascular resistance is unclear, although three-dimensional reconstruction studies sugge...