Development of the pulmonary vasculature: Current understanding and concepts for the future

The pulmonary circulation is a highly specialized vascular bed that physically and functionally connects the heart and the lungs. The interdependence of these two organs is illustrated in embryonic development, when the lung endoderm protrudes into the surrounding mesoderm as the heart tube elongates and folds into structurally distinct chambers. The pulmonary vascular precursors then undergo highly stereotyped cellular maturation and patterning to form a multilayered vascular network that parallels the airways and links the arterial and venous poles of the heart. Upon the first breath, the mature pulmonary circulation is poised to receive the entire cardiac output for efficient gas exchange, and deliver oxygenated blood to the systemic circulation. Disruption of this developmental process can result in congenital defects such as the syndrome tetralogy of Fallot, or differentiation defects leading to persistent pulmonary hypertension of the newborn. Prior studies into the role of angiogenesis and vasculogenesis in pulmonary vascular development have not clearly yielded the identity of pulmonary vascular precursors, or the signals coordinating vascular maturation. We outline key questions on pulmonary vascular development that consider the role of heart-lung interaction in promoting the differentiation and patterning of the pulmonary vasculature.