Mesenchymal stem cell-derived exosomes for cardiac repair: Challenges, standardization gaps and a realistic path to clinical translation

Abstract

Background: Cardiovascular diseases remain the leading cause of mortality worldwide, accounting for approximately one-third of global deaths annually. Despite advances in pharmacological and interventional therapies, the adult mammalian heart exhibits minimal intrinsic regenerative capacity. Mesenchymal stem cell-derived small extracellular vesicles (MSC-sEVs), commonly referred to as exosomes, have emerged as a promising cell-free therapeutic approach for cardiac repair by delivering bioactive molecules that reduce apoptosis, fibrosis and inflammation while promoting angiogenesis.

Objective: This review critically assesses current production, purification and engineering methods for MSC-sEVs, highlighting translational challenges and proposing actionable solutions for clinical development.

Key findings: Preclinical efficacy shows wide variations due to inconsistent isolation methods, dosing protocols and animal models. A standardized potency assay correlating with cardiac functional outcomes is lacking. While completed phase I trials confirm safety, no controlled phase II/III efficacy trials for cardiac indications have been reported. Engineered sEVs demonstrate improved targeting in rodents, but human translation remains unproven. Major barriers include the absence of validated potency assays, GMP-compatible standardization, and large-animal efficacy data.

Conclusion: MSC-sEVs represent a promising investigational platform requiring substantial methodological advancement before clinical translation. Significant hurdles, particularly the absence of validated potency assays, manufacturing standardization, and controlled efficacy trials, must be overcome before regulatory authorization can realistically be contemplated. The timeline for regulatory approval remains uncertain and depends on successful completion of these prerequisites.

Keywords

cardiac regeneration / clinical translation / microRNA / MSC-derived exosomes / regenerative medicine / therapeutic engineering

References

[1] Vaduganathan M, Mensah GA, Turco JV, Fuster V, Roth GA. The global burden of cardiovascular diseases and risk: a compass for future health. American College of Cardiology Foundation Washington DC; 2022: 2361–2371.

[2] Tenreiro MF, Louro AF, Alves PM, Serra M. Next generation of heart regenerative therapies: progress and promise of cardiac tissue engineering. NPJ Regen Med. 2021; 6(1): 30.

[3] Chong B, Jayabaskaran J, Jauhari SM, et al. Global burden of cardiovascular diseases: projections from 2025 to 2050. Eur J Prev Cardiol. 2025; 32(11): 1001–1015.

[4] Han X, Liao R, Li X, et al. Mesenchymal stem cells in treating human diseases: molecular mechanisms and clinical studies. Signal Transduct Target Ther. 2025; 10(1): 262.

[5] Abolhasani S, Fattahi D, Ahmadi Y, et al. Synergistic effects of micropatterned substrates and transforming growth factor-β1 on differentiation of human mesenchymal stem cells into vascular smooth muscle cells through modulation of Krϋppel-like factor 4: abolhasani et al. In Vitro Cell Dev Biol-Anim. 2025; 61(6): 644–655.

[6] Galipeau J, Sensébé L. Mesenchymal stromal cells: clinical challenges and therapeutic opportunities. Cell Stem Cell. 2018; 22(6): 824–833.

[7] Pînzariu AC, Moscalu R, Soroceanu RP, et al. The Therapeutic Use and Potential of MSCs: advances in Regenerative Medicine. Int J Mol Sci. 2025; 26(7): 3084.

[8] Huang D, Shen H, Xie F, et al. Role of mesenchymal stem cell-derived exosomes in the regeneration of different tissues. J Biol Eng. 2024; 18(1): 36.

[9] Rayat Pisheh H, Sani M. Mesenchymal stem cells derived exosomes: a new era in cardiac regeneration. Stem Cell Res Ther. 2025; 16(1): 16.

[10] Azimian Zavareh V, Eslampoor N, Panahi-Alanagh S, Malekmohammad L, Stanek A. Mesenchymal stem cell-derived exosomes in myocardial infarction repair: therapeutic potential and scaffold-based delivery strategies. Front Pharmacol. 2026; 17: 1762630.

[11] Othman Basri NA, Che Roos NA, Aminuddin A, et al. Mechanistic insights into the cardioprotective effects of mesenchymal stem cell-derived exosomes in myocardial ischemic injury: a systematic review. Pharmaceutics. 2026; 18(3): 346.

[12] González-King H, Rodrigues PG, Albery T, et al. Head-to-head comparison of relevant cell sources of small extracellular vesicles for cardiac repair: superiority of embryonic stem cells. J Extracell Vesicles. 2024; 13(5): e12445.

[13] Roefs MT, Heusermann W, Brans MA, et al. Evaluation and manipulation of tissue and cellular distribution of cardiac progenitor cell-derived extracellular vesicles. Front Pharmacol. 2022; 13: 1052091.

[14] Tzng E, Bayardo N, Ikeda G, et al. Molecular mechanisms of exosomes from human iPSC-cardiomyocytes and mesenchymal stem cells in restoring the injured myocardium. J Am Heart Assoc. 2025; 14(21): e037005.

[15] Wang W, Qiao S, Kong X, Zhang G, Cai Z. The role of exosomes in immunopathology and potential therapeutic implications. Cell Mol Immunol. 2025; 22: 975-995.

[16] Wang Y, Zhu J, Ma Q, et al. Trends in mesenchymal stem cell-derived extracellular vesicles clinical trials 2014–2024: is efficacy optimal in a narrow dose range? Front Med. 2025; 12: 1625787.

[17] Welsh JA, Goberdhan DC, O'Driscoll L, et al. Minimal information for studies of extracellular vesicles (MISEV2023): from basic to advanced approaches. J Extracell Vesicles. 2024; 13(2): e12404.

[18] Meng H, Cheng W, Wang L, et al. Mesenchymal stem cell exosomes in the treatment of myocardial infarction: a systematic review of preclinical in vivo studies. J Cardiovasc Transl Res. 2022; 15(2): 317–339.

[19] Mao L, Yue Z, Zhu D, Lu C, Cheng K. Exosomes: Bridge metabolic regulation in cardiac repair. NPJ Biomed Innov. 2025; 2(1): 21.

[20] Wang Y, Hou M, Duan S, et al. Macrophage-targeting gene silencing orchestrates myocardial microenvironment remodeling toward the anti-inflammatory treatment of ischemia-reperfusion (IR) injury. Bioact Mater. 2022; 17: 320–333.

[21] Tan F, Li X, Wang Z, Li J, Shahzad K, Zheng J. Clinical applications of stem cell-derived exosomes. Signal Transduct Target Ther. 2024; 9(1): 17.

[22] van der Pol A, Peters MC, Jorba I, et al. Preclinical extracellular matrix-based treatment strategies for myocardial infarction: a systematic review and meta-analysis. Commun Med. 2025; 5(1): 95.

[23] Nowbar AN, Mielewczik M, Karavassilis M, et al. Discrepancies in autologous bone marrow stem cell trials and enhancement of ejection fraction (DAMASCENE): weighted regression and meta-analysis. BMJ. 2014; 348: g2688.

[24] Zwetsloot PP, Végh AMD, Jansen of Lorkeers SJ, et al. Cardiac stem cell treatment in myocardial infarction: a systematic review and meta-analysis of preclinical studies. Circ Res. 2016; 118(8): 1223–1232.

[25] Mostafavi S, Arasteh A, Montazeri SMM, et al. microRNAs shuttled by mesenchymal stromal cell-derived exosomes in coronary artery disease: a systematic review of preclinical studies. BioImpacts: BI. 2025; 15: 30989.

[26] Chen Z, Xia X, Yao M, et al. The dual role of mesenchymal stem cells in apoptosis regulation. Cell Death Dis. 2024; 15(4): 250.

[27] Gulati R, Nandi D, Sarkar K, et al. Exosomes as theranostic targets: implications for the clinical prognosis of aggressive cancers. Front Mol Biosci. 2022; 9: 890768.

[28] Abolhasani S, Ahmadi Y, Fattahi D, Rostami Y, Chollou KM. microRNA-Mediated Regulation of Oxidative Stress in Cardiovascular Diseases. J Clin Lab Anal. 2025; 39(9): e70017.

[29] Zhang W, Wang T, Xue Y, et al. Research progress of extracellular vesicles and exosomes derived from mesenchymal stem cells in the treatment of oxidative stress-related diseases. Front Immunol. 2023; 14: 1238789.

[30] Pan Q, Wang Y, Lan Q, et al. Exosomes derived from mesenchymal stem cells ameliorate hypoxia/reoxygenation-injured ECs via transferring MicroRNA-126. Stem Cells Int. 2019; 2019(1): 2831756.

[31] Wang Y, Shen Y. Exosomal miR-455-3p from BMMSCs prevents cardiac ischemia-reperfusion injury. Hum Exp Toxicol. 2022; 41: 09603271221102508.

[32] Lindsey ML, Bolli R, Canty Jr JM, et al. Guidelines for experimental models of myocardial ischemia and infarction. Am J Physiol-Heart Circ Physiol. 2018; 314(4): H812–H838.

[33] Wang W, Zhao Y, Li H, et al. Exosomes secreted from mesenchymal stem cells mediate the regeneration of endothelial cells treated with rapamycin by delivering pro-angiogenic microRNAs. Exp Cell Res. 2021; 399(1): 112449.

[34] Ma J, Zhao Y, Sun L, et al. Exosomes derived from Akt-modified human umbilical cord mesenchymal stem cells improve cardiac regeneration and promote angiogenesis via activating platelet-derived growth factor D. Stem Cells Transl Med. 2017; 6(1): 51–59.

[35] Zhang J, Chen C, Hu B, et al. Exosomes derived from human endothelial progenitor cells accelerate cutaneous wound healing by promoting angiogenesis through Erk1/2 signaling. Int J Biol Sci. 2016; 12(12): 1472.

[36] Abolhasani S, Ahmadi Y, Rostami Y, Fattahi D. The role of MicroRNAs in mesenchymal stem cell differentiation into vascular smooth muscle cells. Cell Div. 2025; 20(1): 6.

[37] Laham-Karam N, Mushimiyimana I, Hokkanen K, Ylä-Herttuala S. Role of non-coding RNAs in physiological and pathological angiogenesis. Curr Opin Physiol. 2023; 35: 100690.

[38] Kumar A, Deep G. Exosomes in hypoxia-induced remodeling of the tumor microenvironment. Cancer Lett. 2020; 488: 1–8.

[39] Dong B, Qiu Y, Liu Z, et al. Manipulating bioactivities of endothelial progenitor cell-derived exosomes for promoting angiogenesis in ischemic vascular diseases. Nano Today. 2023; 48: 101758.

[40] Zhang L, Ouyang P, He G, et al. Exosomes from microRNA-126 overexpressing mesenchymal stem cells promote angiogenesis by targeting the PIK3R2-mediated PI3K/Akt signalling pathway. J Cell Mol Med. 2021; 25(4): 2148–2162.

[41] Duan S, Wang C, Xu X, et al. Peripheral serum exosomes isolated from patients with acute myocardial infarction promote endothelial cell angiogenesis via the miR-126-3p/TSC1/mTORC1/HIF-1α pathway. Int J Nanomed. 2022; 17: 1577–1592

[42] Alhasan L. MiR-126 modulates angiogenesis in breast cancer by targeting VEGF-A-mRNA. Asian Pac J Cancer Prev: APJCP. 2019; 20(1): 193.

[43] Zhu D, Wang Y, Thomas M, et al. Exosomes from adipose-derived stem cells alleviate myocardial infarction via microRNA-31/FIH1/HIF-1α pathway. J Mol Cell Cardiol. 2022; 162: 10–19.

[44] Chen J, Shen Z, Chen B, et al. Apoptotic vesicles derived from bone marrow mesenchymal stem cells increase angiogenesis in a hind limb ischemia model via the NAMPT/SIRT1/FOXO1 axis. Stem Cell Res Ther. 2025; 16(1): 105.

[45] Qin Z, Li Y, Li J, et al. Exosomal STAT1 derived from high phosphorus-stimulated vascular endothelial cells induces vascular smooth muscle cell calcification via the Wnt/β-catenin signaling pathway. Int J Mol Med. 2022; 50(6): 139.

[46] Zhang Y, Du H, Ran Q, et al. Murine hindlimb ischemia models: a narrative review. Front Cardiovasc Med. 2025; 12: 1700963.

[47] Della-Morte D, Rundek T. The role of shear stress and arteriogenesis in maintaining vascular homeostasis and preventing cerebral atherosclerosis. Brain Circ. 2015; 1(1): 53–62.

[48] Tariq H, Bukhari SZ, An R, Dong J, Ihsan A, Younis MR. Stem cell-derived exosome delivery systems for treating atherosclerosis: the new frontier of stem cell therapy. Mater Today Bio. 2025; 30: 101440.

[49] Shu Y, Luo Z, Tang Z, et al. Stem cell-derived extracellular vesicles-mediated bone regeneration: mechanisms, targeted delivery, and clinical perspectives in promoting angiogenesis. Front Bioeng Biotechnol. 2026; 14: 1784567.

[50] Zavareh VA, Eslampoor N, Panahi-Alanagh S, Malekmohammad L, Stanek A. Mesenchymal stem cell-derived exosomes in myocardial infarction repair: therapeutic potential and scaffold-based delivery strategies. Front Pharmacol. 2026; 17: 1762630.

[51] Hu J, Chen X, Li P, et al. Exosomes derived from human amniotic fluid mesenchymal stem cells alleviate cardiac fibrosis via enhancing angiogenesis in vivo and in vitro. Cardiovasc Diagn Ther. 2021; 11(2): 348.

[52] Han Q, Wang S, Chen D, Gan D, Wang T. Exosomes derived from human umbilical cord mesenchymal stem cells reduce tendon injuries via the miR-27b-3p/ARHGAP5/RhoA signaling pathway: influences of hucMSC-exosomes in tendon injuries. Acta Biochim Biophys Sin. 2022; 54(2): 232.

[53] Wang H-S, Lin S, Yu H-M. Exosome-mediated repair of intervertebral disc degeneration: the potential role of miRNAs. Curr Stem Cell Res Ther. 2024; 19(6): 798–808.

[54] Yang Y, Huang H, Li Y. Roles of exosomes and exosome-derived miRNAs in pulmonary fibrosis. Front Pharmacol. 2022; 13: 928933.

[55] Song J, Sun T, Tang Z, et al. Exosomes derived from smooth muscle cells ameliorate diabetes-induced erectile dysfunction by inhibiting fibrosis and modulating the NO/cGMP pathway. J Cell Mol Med. 2020; 24(22): 13289–13302.

[56] Gan Y, Wang C, Liao R, et al. Myocardial infarction serum preconditioning bone marrow mesenchymal stem cell-derived exosomes enhance anti-fibrosis in rat myocardial infarction hearts. Mol Cell Biochem. 2025; 480(7): 4417–4429.

[57] Liu Y, Guan R, Yan J, Zhu Y, Sun S, Qu Y. Mesenchymal stem cell-derived extracellular vesicle-shuttled microRNA-302d-3p represses inflammation and cardiac remodeling following acute myocardial infarction. J Cardiovasc Transl Res. 2022; 15(4): 754–771.

[58] Xie L, Long X, Mo M, et al. Bone marrow mesenchymal stem cell-derived exosomes alleviate skin fibrosis in systemic sclerosis by inhibiting the IL-33/ST2 axis via the delivery of microRNA-214. Mol Immunol. 2023; 157: 146–157.

[59] Dhama K, Latheef SK, Dadar M, et al. Biomarkers in stress related diseases/disorders: diagnostic, prognostic, and therapeutic values. Front Mol Biosci. 2019; 6: 465402.

[60] Barton AK, Craig NJ, Loganath K, et al. Myocardial fibroblast activation after acute myocardial infarction: a positron emission tomography and magnetic resonance study. J Am Coll Cardiol. 2025; 85(6): 578–591.

[61] Luther KM, Haar L, McGuinness M, et al. Exosomal miR-21a-5p mediates cardioprotection by mesenchymal stem cells. J Mol Cell Cardiol. 2018; 119: 125–137.

[62] Zhang X, Dong S, Jia Q, et al. The microRNA in ventricular remodeling: the miR-30 family. Biosci Rep. 2019; 39(8): BSR20190788.

[63] Ansarian MA, Fatahichegeni M, Wang Y, Ren J, Wang X. Harnessing the power of exosomes in leukemia: from molecular messengers to clinical applications. Discov Oncol. 2025; 16(1): 1–30.

[64] Zhidu S, Ying T, Rui J, Chao Z. Translational potential of mesenchymal stem cells in regenerative therapies for human diseases: challenges and opportunities. Stem Cell Res Ther. 2024; 15(1): 266.

[65] Consortium M. Minimal information for studies of extracellular vesicles (MISEV2023): from basic to advanced approaches. J Extracell Vesicles. 2024; 13(2): e12404.

[66] Kim T, Hong JW, Lee LP. Efficient methods of isolation and purification of extracellular vesicles. Nano Converg. 2025; 12(1): 45.

[67] Chen Y, Xu Y, Zheng Y, et al. Harnessing 3D cultured MSC exosomes through tangential flow filtration for enhanced diabetic wound healing. Stem Cells Transl Med. 2025; 14(12): szaf064.

[68] Song X, Crommen J, Fillet M. Isolation of blood-derived extracellular vesicles for disease diagnosis: methods, challenges, and applications. J Pharm Anal. Forthcoming 2026.

[69] Venturella M, Navaei A, Zocco D. Comprehensive characterization and in vitro functionality study of small extracellular vesicles isolated by different purification methods from mesenchymal stem cell cultures. Int J Mol Sci. 2025; 26(21): 10602.

[70] Williams S, Fernandez-Rhodes M, Law A, Peacock B, Lewis MP, Davies OG. Comparison of extracellular vesicle isolation processes for therapeutic applications. J Tissue Eng. 2023; 14: 20417314231174609.

[71] Yang M, Guo J, Fang L, et al. Quality and efficiency assessment of five extracellular vesicle isolation methods using the resistive pulse sensing strategy. Anal Methods. 2024; 16(32): 5536–5544.

[72] Al-Jipouri A, Almurisi SH, Al-Japairai K, Bakar LM, Doolaanea AA. Liposomes or extracellular vesicles: a comprehensive comparison of both lipid bilayer vesicles for pulmonary drug delivery. Polymers. 2023; 15(2): 318.

[73] George E, Bosse K. Initial experience implementing a structured review service for non-GLP study data intended to support regulatory submissions at an academic institution. Cytotherapy. 2025; 27(5): S119.

[74] Costa-Ferro ZSM, Rocha GV, da Silva KN, et al. GMP-compliant extracellular vesicles derived from umbilical cord mesenchymal stromal cells: manufacturing and pre-clinical evaluation in ARDS treatment. Cytotherapy. 2024; 26(9): 1013–1025.

[75] Ahmadian S, Jafari N, Tamadon A, Ghaffarzadeh A, Rahbarghazi R, Mahdipour M. Different storage and freezing protocols for extracellular vesicles: a systematic review. Stem Cell Res Ther. 2024; 15(1): 453.

[76] Wiest EF, Zubair AC. Generation of current good manufacturing practices-grade mesenchymal stromal cell-derived extracellular vesicles using automated bioreactors. Biology. 2025; 14(3): 313.

[77] Saleem M, Shahzad KA, Marryum M, et al. Exosome-based therapies for inflammatory disorders: a review of recent advances. Stem Cell Res Ther. 2024; 15(1): 477.

[78] Abolhasani S, Ahmadi Y. MicroRNAs as mediators of mechanotransduction: from fundamental mechanisms to therapeutic applications. Cell Biochem Biophys. 2025; 83: 1–18.

[79] Tarvirdizadeh T, Mentkowski K, Manzanero C, Eagler L, Potekar G, Lang J. Surface engineering enhances the therapeutic potential of systemically delivered extracellular vesicles following acute myocardial infarction. Circulation. 2024; 150(Suppl_1): A4147221–A.

[80] Guarro M, van Veen S, Borrós S, Albertazzi L, Lecina M, Fornaguera C. Quantitative and qualitative comparison of mRNA loading techniques into extracellular vesicles. Biomed Pharmacother. 2025; 193: 118813.

[81] Li X, Gao Y, Zhang Z, et al. Biosafety considerations triggered by genome-editing technologies. Biosaf Health. 2025; 7(03): 141–151.

[82] de Abreu RC, Fernandes H, da Costa Martins PA, et al. Native and bioengineered extracellular vesicles for cardiovascular therapeutics. Nat Rev Cardiol. 2020; 17(11): 685–697.

[83] Hausenloy DJ, Chilian W, Crea F, et al. The coronary circulation in acute myocardial ischaemia/reperfusion injury: a target for cardioprotection. Cardiovasc Res. 2019; 115(7): 1143–1155.

[84] Vekstein AM, Wendell DC, DeLuca S, et al. Targeted delivery for cardiac regeneration: comparison of intra-coronary infusion and intra-myocardial injection in porcine hearts. Front Cardiovasc Med. 2022; 9: 833335.

[85] Rufaihah AJ, Yasa IC, Ramanujam VS, et al. Angiogenic peptide nanofibers repair cardiac tissue defect after myocardial infarction. Acta Biomater. 2017; 58: 102–112.

[86] Vandergriff A, Huang K, Shen D, et al. Targeting regenerative exosomes to myocardial infarction using cardiac homing peptide. Theranostics. 2018; 8(7): 1869.

[87] Lu P, Ruan D, Huang M, et al. Harnessing the potential of hydrogels for advanced therapeutic applications: current achievements and future directions. Signal Transduct Target Ther. 2024; 9(1): 166.

[88] Lv Q, Zhou D, He Y, Xu T, Qiu X, Zeng J. Engineering functional electroconductive hydrogels for targeted therapy in myocardial infarction repair. Bioact Mater. 2025; 49: 172–192.

[89] Ni Y, Hua Y, He Z, et al. Release of exosomes from injectable silk fibroin and alginate composite hydrogel for treatment of myocardial infarction. J Biomater Appl. 2024; 39(2): 139–149.

[90] Huang C, Zhang X, Wu S-X, Chang Q, Zheng Z-K, Xu J. Cardioprotective effects of hUCMSCs-Exosi-EGR1 MN patch in MI/RI by modulating oxidative stress and mitophagy. Mater Today Bio. 2025; 31: 101500.

[91] Ran D, Wang Z, Yu J, et al. Exercise-primed exosomes in an injectable hydrogel promote myocardial repair via angiogenesis and ferroptosis inhibition. Mater Today Bio. 2026; 38:; 38:103035.

[92] Lundy DJ, Chau ZL, Chen SY, et al. Beyond extracellular vesicle (EV) hype: practical solutions and remaining hurdles in EV research, manufacturing, and clinical translation. Adv Sci. 2026; 13(26): e21913.

[93] Chang M, Zhou W, Sun Y, et al. Metabolism and safety evaluation of mesenchymal stem cell-derived exosomes in vivo. Chin J Pharmacovigil. 2025; 22(9): 967.

[94] Inami N. Safety assessment of multiple systemic administration of human mesenchymal stem cell-conditioned medium for various chronic diseases. PLoS One. 2025; 20(5): e0322497.

[95] Visan KS, Lobb RJ, Ham S, et al. Comparative analysis of tangential flow filtration and ultracentrifugation, both combined with subsequent size exclusion chromatography, for the isolation of small extracellular vesicles. J Extracell Vesicles. 2022; 11(9): 12266.

[96] Wang F, Yang J, Wang G. Exosomes in depression: mechanistic insights, diagnostic potential, and therapeutic opportunities. Mol Psychiatry. 2026: 1–16.

[97] Li B, Wu W, Xu W, Qian H, Ji C. Advances of extracellular vesicles isolation and detection frontier technology: from heterogeneity analysis to clinical application. J Nanobiotechnology. 2025; 23(1): 1–42.

[98] Chen Y-S, Lin E-Y, Chiou T-W, Harn H-J. Exosomes in clinical trial and their production in compliance with good manufacturing practice. Tzu Chi Med J. 2020; 32(2): 113–120.

[99] Zheng Y-L, Wang W-D, Cai P-Y, et al. Stem cell-derived exosomes in the treatment of acute myocardial infarction in preclinical animal models: a meta-analysis of randomized controlled trials. Stem Cell Res Ther. 2022; 13(1): 151.

[100] Mamillapalli R, Cho S, Mutlu L, Taylor HS. Therapeutic role of uterine-derived stem cells in acute kidney injury. Stem Cell Res Ther. 2022; 13(1): 107.

[101] Charles CJ, Li RR, Yeung T, et al. Systemic mesenchymal stem cell-derived exosomes reduce myocardial infarct size: characterization with MRI in a porcine model. Front Cardiovasc Med. 2020; 7: 601990.

[102] Kumagai K, Kawamura T, Torigata K, et al. Hypoxia conditioned adipose-derived stem cell-derived extracellular vesicle therapy improves cardiac function in a rat model of ischemic cardiomyopathy. Regen Ther. 2026; 32: 101105.

[103] Sorop O, van de Wouw J, Chandler S, et al. Experimental animal models of coronary microvascular dysfunction. Cardiovasc Res. 2020; 116(4): 756–770.

[104] van Valkengoed DW, Krekels EH, Knibbe CA. All you need to know about allometric scaling: an integrative review on the theoretical basis, empirical evidence, and application in human pharmacology. Clin Pharmacokinet. 2025; 64(2): 173–192.

[105] Claridge B, Lozano J, Poh QH, Greening DW. Development of extracellular vesicle therapeutics: challenges, considerations, and opportunities. Front Cell Dev Biol. 2021; 9: 734720.

[106] Gallet R, Dawkins J, Valle J, et al. Exosomes secreted by cardiosphere-derived cells reduce scarring, attenuate adverse remodelling, and improve function in acute and chronic porcine myocardial infarction. Eur Heart J. 2017; 38(3): 201–211.

[107] Chae C-W, Choi G, Yoon T, Kwon Y-W. Exosome-based therapy in cardiovascular diseases: a new frontier in cardiovascular disease treatment. Korean Circ J. 2025; 55(6): 461–480.

[108] Vidal-Cales P, Cepas-Guillen PL, Brugaletta S, Sabate M. New interventional therapies beyond stenting to treat ST-segment elevation acute myocardial infarction. J Cardiovasc Dev Dis. 2021; 8(9): 100.

[109] Tompkins BA, Rieger AC, Florea V, Banerjee M, Hare JM. New insights into cell-based therapy for heart failure from the CHART-1 study. Eur J Heart Fail. 2017; 19(11): 1530.

[110] Lee B-C, Kang I, Yu K-R. Therapeutic features and updated clinical trials of mesenchymal stem cell (MSC)-derived exosomes. J Clin Med. 2021; 10(4): 711.

[111] Chae C-W, Choi G, Yoon T, Kwon Y-W. Exosome-based therapy in cardiovascular diseases: a new frontier in cardiovascular disease treatment. Korean Circ J. 2025; 55(6): 461.

[112] Mentkowski KI, Snitzer JD, Rusnak S, Lang JK. Therapeutic potential of engineered extracellular vesicles. AAPS J. 2018; 20(3): 50.

[113] Wang Z, Gao N, Zhang J, Guo B. Mesenchymal stem cells and their exosomes in cardiac repair: advances and future directions. Int J Drug Discov Pharmacol. 2026; 5(2): 100014.

[114] Lotfy A, AboQuella NM, Wang H. Mesenchymal stromal/stem cell (MSC)-derived exosomes in clinical trials. Stem Cell Res Ther. 2023; 14(1): 66.

[115] Shojaei S, Mirhosseini SA, Mousavi A, et al. The effect of exosome-related therapy in cardiac revascularization procedures: a systematic review. BMC Cardiovasc Disord. 2025; 25(1): 793.

[116] Tran T-L, Luong T-H, Pham T-A, Nguyen T-N. A comprehensive review of clinical trials and Progress in stem cell therapies for advanced heart failure. Regen Ther. 2025; 30: 812–837.

[117] Xu CM, Sabe SA, Brinck-Teixeira R, Sabra M, Sellke FW, Abid MR. Visualization of cardiac uptake of bone marrow mesenchymal stem cell-derived extracellular vesicles after intramyocardial or intravenous injection in murine myocardial infarction. Physiol Rep. 2023; 11(6): e15568.

[118] Uman S, Worthington K, Dominic J, Atluri P, Burdick JA. Comparison of technologies for manufacturing extracellular vesicles for therapeutic applications. Trends Biotechnol. 2025; 44(4): 1079–1099.

[119] Jeyaraman M, Jeyaraman N, Ramasubramanian S, Nallakumarasamy A. Quality, commercialization, and equity in mesenchymal stem cell and extracellular vesicle therapies. Mesenchymal Stem Cells and Extracellular Vesicles as Next-Generation Therapeutics: Elsevier; 2026: 121–140.

[120] Kalodimou VE, Muthu S. Regulatory concerns for exosome-and other extracellular vesicle-based diagnostics and medicine products. Extracellular vesicles for therapeutic and diagnostic applications: Elsevier; 2025: 523–536.

[121] Rossello-Gelabert M, Escacena N, Igartua M, Santos-Vizcaino E, Hernandez RM. Translational pathways for MSC secretome therapies: from bioprocessing to delivery. Trends Biotechnol. 2026; 44.

[122] Park K-S, Ha DH, Lee JH, et al. Quantitative proteomic and functional comparison of extracellular vesicles from multiple adipose tissue mesenchymal stem cell donors. Extracell Vesicles Circ Nucleic Acids. 2026; 7(1): 425.

[123] Ranjan P, Colin K, Dutta RK, Verma SK. Challenges and future scope of exosomes in the treatment of cardiovascular diseases. J Physiol. 2023; 601(22): 4873–4893.

[124] Bois A, Grandela C, Gallant J, Mummery C, Menasché P. Revitalizing the heart: strategies and tools for cardiomyocyte regeneration post-myocardial infarction. NPJ Regen Med. 2025; 10(1): 6.

[125] Milani-Nejad N, Janssen PM. Small and large animal models in cardiac contraction research: advantages and disadvantages. Pharmacol Ther. 2014; 141(3): 235–249.

[126] Bayzigitov DR, Medvedev SP, Dementyeva EV, et al. Human induced pluripotent stem cell-derived cardiomyocytes afford new opportunities in inherited cardiovascular disease modeling. Cardiol Res Pract. 2016; 2016(1): 3582380.

[127] De Villiers C, Riley P. Mouse models of myocardial infarction: comparing permanent ligation and ischaemia-reperfusion. DMM Dis Models Mech. 2020; 13(11): dmm046565.

[128] Damluji AA, Forman DE, Wang TY, et al. Management of acute coronary syndrome in the older adult population: a scientific statement from the American Heart Association. Circulation. 2023; 147(3): e32–e62.

[129] Wang M, Chen Y, Xu B, et al. Recent advances in the roles of extracellular vesicles in cardiovascular diseases: pathophysiological mechanisms, biomarkers, and cell-free therapeutic strategy. Mol Med. 2025; 31(1): 169.

[130] Poupardin R, Wolf M, Strunk D. Adherence to minimal experimental requirements for defining extracellular vesicles and their functions. Adv Drug Deliv Rev. 2021; 176: 113872.

[131] Sidhom K, Obi PO, Saleem A. A review of exosomal isolation methods: is size exclusion chromatography the best option? Int J Mol Sci. 2020; 21(18): 6466.

[132] Escudero-Cernuda S, Eiro N, Fraile M, Vizoso FJ, Fernández-Colomer B, Fernández-Sánchez ML. Limitations and challenges in the characterization of extracellular vesicles from stem cells and serum. Microchim Acta. 2025; 192(5): 311.

[133] Lobb RJ, Becker M, Wen Wen S, et al. Optimized exosome isolation protocol for cell culture supernatant and human plasma. J Extracell Vesicles. 2015; 4(1): 27031.

[134] Zhang S, Li D, Liu L, Shi Q, Ju X. Extracellular vesicles derived from HuMSCs alleviate daunorubicin-induced cardiac microvascular injury via miR-186-5p/PARP9/STAT1 signal pathway. Regen Ther. 2024; 25: 320–330.

[135] Copp G, Viswanathan S, Immunomodulatory potential of enhanced MSC-derived extracellular vesicles. Cytotherapy. 2024; 26(6): S72–S73.

[136] Cheng H, Chang S, Xu R, et al. Hypoxia-challenged MSC-derived exosomes deliver miR-210 to attenuate post-infarction cardiac apoptosis. Stem cell Res Ther. 2020; 11(1): 224.

[137] Ling F, Yang W, Yuan M, et al. Delivery of bone marrow mesenchymal stem cell-derived exosomes into fibroblasts attenuates intestinal fibrosis by weakening its transdifferentiation via the CCN2-TGF-β axis. Sci Rep. 2025; 15(1): 18048.

[138] Yadid M, Lind JU, Ardoña HAM, et al. Endothelial extracellular vesicles contain protective proteins and rescue ischemia-reperfusion injury in a human heart-on-chip. Sci Transl Med. 2020; 12(565): eaax8005.

[139] Matta A, Nader V, Lebrin M, et al. Pre-conditioning methods and novel approaches with mesenchymal stem cells therapy in cardiovascular disease. Cells. 2022; 11(10): 1620.

[140] Kleinbongard P, Lieder HR, Skyschally A, Heusch G. No robust reduction of infarct size and no-reflow by metoprolol pretreatment in adult Göttingen minipigs. Basic Res Cardiol. 2023; 118(1): 23.

[141] Qian C, Yang C, Lu M, et al. Activating AhR alleviates cognitive deficits of Alzheimer's disease model mice by upregulating endogenous Aβ catabolic enzyme Neprilysin. Theranostics. 2021; 11(18): 8797.

[142] Chen Y, Qi W, Wang Z, Niu F. Exosome source matters: a comprehensive review from the perspective of diverse cellular origins. Pharmaceutics. 2025; 17 (2): 147. PMID: 40006514. PMCID: PMC11858990.

[143] Phutiyothin C, Pattanapanyasat K, Kumphune S. Small vesicles, big potential: a review of innovative exosome delivery and molecular mechanisms in preclinical myocardial infarction models. Anim Models Exp Med. 2026; 9(3): 486–504.

[144] Jansen of Lorkeers SJ, Eding JEC, Vesterinen HM, et al. Similar effect of autologous and allogeneic cell therapy for ischemic heart disease: systematic review and meta-analysis of large animal studies. Circ Res. 2015; 116(1): 80–86.

[145] Lan T, Tang T-T, Di J-J, et al. Safety evaluation of repeated administration of umbilical cord mesenchymal stem cell-derived exosomes. Stem Cell Res Ther. 2026; 17.

[146] Weiss L, Macleod H, Maguire PB. Platelet-derived extracellular vesicles in cardiovascular disease and treatment–from maintaining homeostasis to targeted drug delivery. Curr Opin Hematol. 2025; 32(1): 4–13.

[147] Tolomeo AM, Zuccolotto G, Malvicini R, et al. Biodistribution of intratracheal, intranasal, and intravenous injections of human mesenchymal stromal cell-derived extracellular vesicles in a mouse model for drug delivery studies. Pharmaceutics. 2023; 15(2): 548.

[148] Nguyen QT, Dinh NTH, Hang NT, et al. Safety evaluation of extracellular vesicles derived from hypoxia primed mesenchymal stem cells of umbilical cord and adipose tissue. Sci Rep. 2025; 15(1): 36267.

[149] Xu W, Jieda X, Wu Y, et al. Safety, efficacy and bio-distribution analysis of exosomes derived from human umbilical cord mesenchymal stem cells for effective treatment of bronchopulmonary dysplasia by intranasal administration in mice model. Int J Nanomed. 2025; 20: 2521–2553.

[150] Jahangiri B, Khalaj-Kondori M, Asadollahi E, Kian Saei A, Sadeghizadeh M. Dual impacts of mesenchymal stem cell-derived exosomes on cancer cells: unravelling complex interactions. J Cell Commun Signal. 2023; 17(4): 1229–1247.

[151] Tang X-L, Bolli R. Repeated intravenous administration of mesenchymal stromal cells produces cumulative beneficial effects in chronic ischemic cardiomyopathy. Tex Heart Inst J. 2023; 50(5): e238244.

[152] Gonzalez-King H, Rodrigues P, Albery T, Tangruksa B, Gurrapu R, Silva A. Head-to-head comparison of relevant cell sources of small extracellular vesicles for cardiac repair: superiority of embryonic stem cells. J Extracell Vesicles. 2024; 13: e12445.

[153] Wang AYL, Kao H-K, Liu Y-Y, Loh CYY. Engineered extracellular vesicles derived from pluripotent stem cells: a cell-free approach to regenerative medicine. Burns Trauma. 2025; 13: tkaf013.

[154] Rayat Pisheh H, Sani M. Mesenchymal stem cells derived exosomes: A new era in cardiac regeneration. Stem Cell Res Ther. 2025; 16: 16.

[155] Bryl R, Kulus M, Bryja A, et al. Cardiac progenitor cell therapy: mechanisms of action. Cell Biosci. 2024; 14(1): 30.

[156] Tominaga Y, Kawamura T, Ito E, et al. Pleiotropic effects of extracellular vesicles from induced pluripotent stem cell–derived cardiomyocytes on ischemic cardiomyopathy: a preclinical study. J Heart Lung Transplant. 2024; 43(1): 85–99.

[157] Ranjan P, Dutta RK, Colin K, et al. Bone marrow-fibroblast progenitor cell-derived small extracellular vesicles promote cardiac fibrosis via miR-21-5p and integrin subunit αV signalling. J Extracell Biol. 2024; 3(6): e152.

[158] Ma T, He Y, Yang J, et al. Mesenchymal stromal cell-derived extracellular vesicles mediate mitochondrial delivery in injury: mechanistic insights, evidentiary tiers, and translational challenges. Stem Cell Rev Rep.. 2026; 22(6): 2768-2787.

[159] Chang W, Li P. Bone marrow mesenchymal stromal cell-derived small extracellular vesicles: a novel therapeutic agent in ischemic heart diseases. Front Pharmacol. 2023; 13: 1098634.

[160] Lundy DJ, Burnouf T, Lai JJ, Hill JH, Hsieh PC. Scalable technologies in the manufacture and deployment of cell-free cardiac therapies. Trends Biotechnol. 2025; 43(11): 2786–2802.

[161] Handa K, Kawamura T, Mano Y, et al. Nanomicelle-based Multi-mRNA delivery promotes cardiac repair after myocardial infarction. Small Sci. 2026; 6(5): e202500521.

[162] Wysoczynski M, Bolli R. A realistic appraisal of the use of embryonic stem cell-based therapies for cardiac repair. Eur Heart J. 2020; 41(25): 2397–2404.

[163] Wang CK, Tsai TH, Lee CH. Regulation of exosomes as biologic medicines: regulatory challenges faced in exosome development and manufacturing processes. Clin Transl Sci. 2024; 17(8): e13904.

[164] Farahzadi R, Fathi E, Valipour B, Ghaffary S. Stem cells-derived exosomes as cardiac regenerative agents. IJC Heart Vasc. 2024; 52: 101399.

[165] Ahn S-H, Ryu S-W, Choi H, You S, Park J, Choi C. Manufacturing therapeutic exosomes: from bench to industry. Mol Cells. 2022; 45(5): 284–290.

[166] Jing Y, Cai Y, Li Q, et al. Empagliflozin-pretreated BMSC exosomes attenuate myocardial ischemia-reperfusion injury by enhancing atad3a/pink1-dependent mitophagy. Stem Cell Res Ther. 2025; 16(1): 595.

[167] Chaudhari AP, Budayr OM, Bonacquisti EE, et al. The status of extracellular vesicles as drug carriers and therapeutics. Nat Rev Bioeng. 2026; 4(4): 301-318.

[168] Gong Z-T, Xiong Y-Y, Ning Y, et al. Nicorandil-pretreated mesenchymal stem cell-derived exosomes facilitate cardiac repair after myocardial infarction via promoting macrophage M2 polarization by targeting miR-125a-5p/TRAF6/IRF5 signaling pathway. Int J Nanomed. 2024; 19: 2005–2024.

[169] Calascibetta F, Martorana A, Lo Pinto M, et al. GMP-compliant, serum-free cultures preserve therapeutic potential of extracellular vesicles from human mesenchymal stromal cells. Front Cell Dev Biol. 2025; 13: 1633912.

[170] Adlerz K, Patel D, Rowley J, Ng K, Ahsan T. Strategies for scalable manufacturing and translation of MSC-derived extracellular vesicles. Stem Cell Res. 2020; 48: 101978.

[171] Li Y, Tasoudis P, Huang K, Cheng K. Abstract Mo044: minimally invasive delivery of mesenchymal stem cell-derived exosomes improves heart repair in pigs. Circ Res. 2024; 135(Suppl_1): AMo044–AMo.

[172] Tertel T, Giebel B, Lee RH, et al. ISCT 2025 exosomes signature series: a thematic synthesis for advancing msc ev therapies. Cytotherapy. 2025; 28(3): 102016.

[173] Dahiya A, Singh K, Ashish A, et al. Global harmonization in advanced therapeutics: balancing innovation, safety, and access. Pers Med. 2025; 22(3): 181–191.

Rights & permissions

2026 The Author(s). Clinical and Translational Discovery published by John Wiley & Sons Australia, Ltd on behalf of Shanghai Institute of Clinical Bioinformatics.