# Extracellular vesicles in cardiac surgery: unlocking new frontiers in cardioprotection and patient outcomes

## TL;DR

Extracellular vesicles (EVs) show promise as biomarkers and therapies in cardiac surgery, offering new ways to improve patient outcomes and cardioprotection.

## Contribution

This review highlights the emerging roles of EVs in CABG and valvular surgery, emphasizing their diagnostic and therapeutic potential.

## Key findings

- EVs are linked to systemic inflammation, myocardial injury, and cognitive dysfunction in CABG.
- Endothelial- and platelet-derived EVs correlate with endothelial injury and outcomes in valvular surgery.
- Stem cell-derived EVs demonstrate cardioprotective effects in preclinical studies.

## Abstract

Cardiac surgery, while life-saving, induces profound physiological stress due to ischemia–reperfusion injury (IRI), systemic inflammation, and endothelial dysfunction, particularly in procedures involving cardiopulmonary bypass. In this complex setting, extracellular vesicles (EVs) have emerged as both biomarkers and potential mediators of cardiovascular injury and repair.

This narrative review explores the multifaceted roles of EVs in cardiac surgery, with a focus on coronary artery bypass grafting (CABG) and valve repair or replacement. The review examines the diagnostic and therapeutic implications of circulating EVs and their role in graft patency, perioperative complications, myocardial protection, and vascular remodeling.

We summarize current evidence regarding the biogenesis, classification, and engineering of EVs, highlighting their ability to transport bioactive molecules that modulate inflammation, coagulation, and apoptosis. In CABG, EVs have been linked to systemic inflammatory response, myocardial injury, and postoperative cognitive dysfunction. In valvular heart surgery and transcatheter procedures, endothelial- and platelet-derived EVs correlate with endothelial injury, shear stress, and postoperative outcomes. Preclinical studies indicate that stem cell-derived EVs exert cardioprotective effects by reducing apoptosis, promoting angiogenesis, and reprogramming macrophages.

EVs represent a promising frontier in cardiac surgery, offering opportunities for risk stratification, real-time monitoring, and novel therapeutic strategies. Further translational research and standardized clinical protocols are needed to integrate EV profiling into perioperative care and to explore the full potential of EV-based therapies in cardioprotection and vascular healing.