Abstract-The pulmonary vein is sleeved by myocardium, which is a major source of atrial fibrillation and is involved in congenital sinus venosus defects. Little is known about the cellular origin and mechanism of formation of the pulmonary myocardium. We observed a biphasic process of pulmonary myocardium formation in mice. Firstly, a myocardial cell population forms de novo at the connection of the pulmonary vein and the atrium. Genetic labeling revealed that atrial cells do not contribute to this population, indicating it forms by differentiation of pulmonary mesenchymal cells. Secondly, these pulmonary myocardial cells initiate a phase of rapid proliferation and form the pulmonary myocardial sleeve. Pitx2c-deficient mice do not develop a pulmonary myocardial sleeve because they fail to form the initial pulmonary myocardial cells. Genetic-labeling analyses demonstrated that whereas the systemic venous return derives from Nkx2-5-negative precursors, the pulmonary myocardium derives from Nkx2-5-expressing precursors, indicating a distinct origin of the 2 venous systems. Nkx2-5 and its target gap-junction gene Cx40 are expressed in the atria and in the pulmonary myocardium but not in the systemic venous return, which expresses the essential pacemaker channel Hcn4. When Nkx2-5 protein level was lowered in a hypomorphic model, the pulmonary myocardium switched to a Cx40-negative, Hcn4-positive phenotype resembling that of the systemic venous return. In conclusion, our data suggest a cellular mechanism for pulmonary myocardium formation and highlight the key roles played by Pitx2c and Nkx2-5 in its formation and identity. Key Words: pulmonary myocardium Ⅲ pulmonary vein Ⅲ Nkx2-5 Ⅲ Pitx2c Ⅲ Hcn4 Ⅲ Cx40 Ⅲ differentiation Ⅲ lineage Ⅲ precursor T he pulmonary venous vessels are ensheathed by a myocardial layer known as the pulmonary myocardium. Besides its normal physiological functions, 1 the pulmonary myocardium is a major source of atrial fibrillation. 2 Several possible mechanisms for this pathology have been put forward, including intrinsic pacemaker activity and properties that facilitate reentrance. 3 A related issue, therefore, is whether the formed pulmonary myocardium shares both origin and phenotypic properties with nodal (pacemaker) tissues, 4 -7 such as the sinoatrial node and myocardium of the developing systemic venous return (sinus venosus/sinus horn), or with the atrial myocardium, which has a working myocardial phenotype much less prone to automaticity. The pulmonary myocardium is also involved in congenital cardiac malformations with anomalous connections to the atria or systemic venous return as major defects. 8 Although the morphology and physiology of the pulmonary myocardium have been extensively studied, little is known about the developmental origin and the molecular mechanisms controlling its formation and phenotype. The pulmonary myocardium has been proposed to form from atrial myocardium, which migrates around the pulmonary vein after its connection with the atrium has been established. 9,10...