Remodeling of distal pulmonary arterioles (pAs) associated with marked accumulation of pulmonary artery smooth muscle cells (pASMcs) represents one of the major pathologic features of pulmonary hypertension (PH). We have reported that the transcription factor Twist1 mediates hypoxia-induced PH. However, the mechanism by which endothelial Twist1 stimulates SMC accumulation to distal PAs in PH remains unclear. Here, we have demonstrated that Twist1 overexpression increases the expression of platelet-derived growth factor (PDGFB) in human pulmonary arterial endothelial (HPAE) cells. Hypoxia upregulates the levels of Twist1 and PDGFB in HPAE cells. When we implant hydrogel supplemented with endothelial cells (ECs) on the mouse lung, these ECs form vascular lumen structures and hypoxia upregulates PDGFB expression and stimulates accumulation of αSMA-positive cells in the gel, while knockdown of endothelial Twist1 suppresses the effects. The levels of Twist1 and PDGFB are higher in pAe cells isolated from idiopathic pulmonary arterial hypertension (ipAH) patients compared to those from healthy controls. IPAH patient-derived PAE cells stimulate accumulation of αSMA-positive cells in the implanted gel, while Twist1 knockdown in PAE cells inhibits the effects. Endothelial Twist1-PDGFB signaling plays a key role in αSMA-positive cell proliferation and migration in PH. Pulmonary hypertension (PH) is a multifactorial life-threatening cardiopulmonary disorder 1,2. It is characterized by a sustained increase in pulmonary arterial (PA) pressure, leading to right-sided heart failure 1,2. The current therapeutic options only partially improve symptoms and survival 1,3. Uncontrolled pulmonary artery smooth muscle cell (PASMC) proliferation and accumulation of PASMCs to normally non-muscularized distal PAs are the major histological characteristics of PH 2,4. Thus, we need to understand the mechanism of abnormal SMC proliferation, migration, and their accumulation to distal PAs. In addition to lining vascular structures, endothelial cells (ECs) regulate various physiological functions by secreting angiocrine factors 5. Deregulation of this paracrine mechanism leads to the development of diseases 5. In PH pathology, abnormal ECs release factors that stimulate SMC proliferation (e.g., FGF-2 6 , serotonin 7) or fail to produce factors that physiologically suppress SMC proliferation (e.g., apelin 8), indicating that aberrant pulmonary arterial EC signaling plays key roles in abnormal SMC accumulation to distal PAs 2. The transcription factor Twist1 controls physiological and pathological angiogenesis in various organs including the lungs 9-14. The levels of Twist1 are upregulated in the lungs of patients with pulmonary arterial hypertension (PAH; WHO group1 PH) 15,16 and mice with type II bone morphogenetic protein receptor (Bmpr2) gene mutation 15 , a gene mutated in familial and idiopathic PAH 17. Twist1 expression also increases in the patients with chronic lung diseases associated with PH such as pulmonary fibrosis 18,19. We have d...