Rationale: Our previous studies found that Na 1 /H 1 exchanger (NHE) activity played an essential role in pulmonary artery smooth muscle cell (PASMC) proliferation and in the development of hypoxiainduced pulmonary hypertension and vascular remodeling. Other investigators recently observed increased expression of the NHE isoform 1 (NHE1) gene in rodents with pulmonary hypertension induced by hypoxia. However, a causal role for the NHE1 gene in pulmonary hypertension has not been determined. Objectives: To determine the causal role of the NHE1 gene in pulmonary hypertension and vascular remodeling. Methods: We used NHE1-null mice to define the role of the NHE1 gene in the development of pulmonary hypertension and remodeling induced by hypoxia and to delineate the NHE1 regulatory pathway. Measurements and Main Results: After 2 weeks of exposure to hypoxia, in contrast to wild-type hypoxic littermates, there was no significant increase in right ventricular systolic pressure, in the ratio of right ventricular to left ventricular plus septal weight [RV/(LV 1 S)], or in medial wall thickness of the pulmonary arterioles in homozygous mice (NHE1 2/2 ). There was a significant decrease in Rho kinase (ROCK1 and ROCK2) expression, accompanied by an increase in p27 expression in NHE1 2/2 mice. Conclusions: Our study demonstrated that deficiency of the NHE1 gene prevented the development of hypoxia-induced pulmonary hypertension and vascular remodeling in mice and revealed a novel regulatory pathway associated with NHE1 signaling. Keywords: Na 1 /H 1 exchanger isoform 1; pulmonary hypertension; vascular remodeling; hypoxia; mouseThe Na 1 /H 1 exchanger (NHE) expressed in many mammalian cell types is a protein localized to the plasma and the mitochondrial inner membrane (1). The function of NHE is to regulate intracellular pH and cell volume by extruding H 1 from and taking up Na 1 into cells (2). Since NHE was first analyzed in 1976 (3) and the first NHE cDNA was cloned in 1989 (4), nine NHE isoforms have been identified and cloned (2), of which NHE isoform 1 (NHE1) is ubiquitously expressed.Pulmonary hypertension caused by many chronic lung diseases associated with prolonged hypoxia can result in right ventricular hypertrophy and heart failure (5). An important pathological feature of pulmonary hypertension is increased medial thickening of the pulmonary artery resulting from hypertrophy and hyperplasia of the pulmonary artery smooth muscle cells (PASMCs) (6, 7). In previous studies, we reported that NHE activity played a significant role in regulation of intracellular pH in PASMCs (8) and found that the inhibition of NHE activity was related to the inhibition of bovine PASMC proliferation induced by growth factors (9, 10). We also found that inhibition of NHE activity significantly reduced pulmonary hypertension and vascular remodeling induced by chronic hypoxia in rats (11). Our studies suggested that NHE activity might play an important role in development of pulmonary hypertension and vascular remodeling.Recently, incre...