Bioengineering extracellular vesicles for enhanced therapeutic functionality and clinical potential in the cardiovascular system

Cardiovascular diseases (CVDs) are a leading cause of morbidity, disability, and mortality worldwide, posing a significant threat to global health. These diseases include myocardial infarction (MI), heart failure (HF), hypertension, atherosclerosis (AS), and other pathological cardiac disorders. Despite notable advances in CVD management, such as cardiac-targeted pharmacotherapies, interventional procedures, and heart transplantation, major challenges persist, including adverse drug effects, postoperative complications, and the persistent shortage of heart donors. Extracellular vesicles (EVs) have recently emerged as a promising therapeutic modality owing to their high delivery efficiency, precise targeting potential, and capacity to promote cardiac repair and regeneration. EVs carry a diverse repertoire of bioactive cargos, including proteins, nucleic acids, lipids, and metabolites, facilitating intercellular regulation of immune response, tissue repair, and regenerative processes. Advances in bioengineered EVs also develop the therapeutic potential by enabling the design of vesicles with enhanced targeting specificity and controlled cargo delivery. This review summarizes the complex interactions between EVs and the cardiovascular system, with particular emphasis on their roles in cellular communication, microenvironment modulation, and immune regulation. We further highlight the regenerative capacity of EVs in cardiovascular repair, and discuss emerging clinical applications of native and bioengineered EVs in cardiovascular homeostasis, remodeling, metabolism, and regeneration. These insights pave the way for further exploration of bioengineered EVs as a novel therapeutic platform in cardiovascular medicine.