Among the leading causes of death and disability worldwide are acute myocardial infarction (AMI) and end-stage heart failure (HF), causing approximately 17 million deaths annually and accounting for 30% of all deaths globally (Ong et al., 2018; Roth et al., 2020). Coronary atherosclerosis underlies the development of myocardial infarction (MI), which contributes to vessel lumen narrowing and ultimately elicits myocardial necrosis due to hypoxia/ischemia. Currently, the primary goal of clinical treatment for such disease is to promptly restore flow in the occluded vessel and restore the ischemic myocardium, commonly performed by direct percutaneous coronary intervention. Intriguingly, however, such interventions can contribute to cardiomyocyte death and myocardial injury (Schirone et al., 2022). Consequently, novel therapies and interventions are urgently required to attenuate adverse ventricular remodeling and mitigate HF.

The heart undergoes a series of structural and functional alterations to adapt to cardiac injury induced by MI, which is known as cardiac remodeling (Zhao et al., 2020). Specifically, cardiac remodeling is a complex pathophysiological process, including inflammation, mitochondria dysfunction, oxidative stress, cardiac hypertrophy, and cardiac fibrosis. The entire process can be divided into two stages, the inflammatory phase and the fibrotic scar revision phase (Schirone et al., 2017; Liu H et al., 2020). The initial phase involves the exposure of intracellular contents into the extracellular environment due to cell necrosis, called damage-associated molecular patterns (DAMPs), triggering and exacerbating sterile inflammation. While the latter phase is attributed to the transdifferentiation of fibroblasts into myofibroblasts stimulated by multiple factors, including inflammatory factors, angiotensin II, and mechanical stress stimulation, which secrete collagen and facilitate scar repair in the infarcted region and maintain the structural integrity of the ventricle (Prabhu and Frangogiannis, 2016; Peet et al., 2020).

During cardiac remodeling, numerous immune cells recruitment to the infarct area, interact with cardiac fibroblasts (CFs) which crucially coordinates the balance between profibrotic and antifibrotic effects (Zaidi et al., 2021). In the initial inflammatory phase of AMI, the recruitment and activation of immune cells, such as macrophages, neutrophils, and monocytes, not only secrete inflammatory mediators to aggravate the inflammation but also shift towards an anti-inflammatory phenotype, which can prevent the release of their contents into the extracellular environment by removing necrotic cellular debris from the MI zone to attenuate inflammation (Ong et al., 2018; Andreadou et al., 2019; Doran et al., 2020). Besides this, the crosstalk between other diverse cells, including mesenchymal stem cells, endothelial cells (ECs), and cardiomyocytes is also essential for maintaining dynamic balance throughout the whole process. Interestingly, however, these cells secrete large numbers of EVs, which carry numerous bioactive substances, including miRNAs, lipids, and proteins. The bioactive substances not only have similar roles to parental cells but are also essential regulators of intercellular communication (Xiong et al., 2021). In general, there are three major subtypes of EVs, apoptotic bodies (ABs), microvesicles (MVs), and exosomes (Sanchez-Alonso et al., 2018), of which the most comprehensively explored are exosomes. In contrast, the least well-studied are ABs.

This review summarizes the dual roles of EVs derived from diverse cells in postinfarction cardiac remodeling, including pro-inflammatory and anti-inflammatory effects in the initial postinfarction inflammatory response and profibrotic and antifibrotic effects in the scar repair phase. Importantly, we discuss the role of crosstalk between these EVs in achieving a coordinated dynamic balance between the inflammatory response and the fibrotic process, which is significant for maladaptive cardiac remodeling after MI. In parallel, we also discuss therapeutic opportunities for targeting EVs that play a significant role in post-infarction cardiac remodeling, including pharmacological preconditioning and engineered modification. These elements will be beneficial in expanding therapeutic strategies for post-infarction cardiac remodeling.

AMI results from myocardial blood flow obstruction due to atherosclerotic plaque rupture or erosion (Ibanez et al., 2018). AMI is currently treated mainly by revascularization procedures such as thrombolysis and coronary intervention. However, recanalizing occluded vessels under long-term ischemic conditions causes additional myocardial damage, termed “I/R injury” (Yellon and Hausenloy, 2007). Such a process is accompanied by a blockage of blood flow, a sudden and dramatic interruption of oxygen and nutrient supply in the blood, a short cessation of mitochondrial oxidative phosphorylation (Frank et al., 2012), a dramatic decrease in available intracellular adenosine triphosphate (ATP), and a reduction in cardiomyocyte contractile function and cardiac stiffness and contracture minutes after the onset of ischemia (Jennings and Reimer, 1991). In the meantime, the myocardial ischemic injury may contribute to substantial cardiomyocyte death via different mechanisms. At the outset of reperfusion, cytosolic calcium overload and massive reactive oxygen species (ROS) generation rupture the mitochondrial membrane and release the contents, which in turn activate the caspase-mediated intrinsic pathway of apoptosis (Schirone et al., 2022). On the other hand, phosphorylation of receptor-interacting protein kinase 3 (RIPK3) is recruited and activated by the receptor-interacting protein kinase 1 (RIPK1), which in turn triggers necroptosis and exacerbate the pathological process after MI (Rodriguez et al., 2016).

The large volume of dead and injured cardiomyocyte contents (including heat shock proteins, organelle debris, and nuclear debris) enter the interstitial matrix, namely, DAMPs (Frangogiannis, 2012; Timmers et al., 2012). Simultaneously, innate immunity is triggered when pattern recognition receptors (PRRs) on leukocytes recognize DAMPs (Suetomi et al., 2019; Silvis et al., 2020). Immediately afterwards, the Toll-like receptor signaling pathway and other numerous inflammatory pathways are activated, thereby inducing proinflammatory cytokine expression, including interleukin 6 (IL-6), interleukin 1β (IL-1β), and tumor necrosis factor α (TNF-α), as well as the expression of chemokines, including monocyte chemotactic protein-1 (MCP-1/CCL2) (Frangogiannis, 2007). Additionally, neutrophils and inflammatory monocytes recruited by chemokine CCL2 activation are recruited to the infarcted heart (Dewald et al., 2005; Ley et al., 2007). On the other hand, when tissues are damaged, nuclear factor κB (NF-κB) is activated in ROS-dependent way and increases the expression of specific cellular genes, which can also eventually stimulate the growth of cells associated with inflammation and immune responses and exacerbate the inflammation even further (Kabe et al., 2005; Sun, 2009).

Short-term inflammatory responses contribute to debris removal, while long-term inflammation can facilitate extracellular matrix degradation and cell death, resulting in infarct size expansion. Consequently, timely resolution of the inflammation is essential for maintaining post-infarction remodeling. At the same time, apoptosis and clearance of neutrophils in the infarcted area is a hallmark that inflammation is beginning to subside (Frangogiannis, 2012; Westman et al., 2016; Ong et al., 2018). As leukocyte infiltration removes dead cells and matrix debris from the infarct and represses inflammatory mediator release, the anti-inflammatory monocyte subsets become dominant (Frangogiannis, 2008; Prabhu and Frangogiannis, 2016). Furthermore, suppressive subsets of other immune cells like lymphocytes, monocytes, and anti-inflammatory macrophages can suppress inflammation in the infarcted heart. Macrophages, in particular, play a crucial role in this process by shifting from a pro-inflammatory to an anti-inflammatory phenotype (Yan et al., 2013). In this way, the post-infarction pathological process moves from the pro-inflammatory response phase to the anti-inflammatory response phase, collectively referred to as the inflammatory response phase (within 3–7 days after MI), and eventually to the scar repair phase (7 days after MI) (Liu S et al., 2020).

In the cardiac tissue remodeling phase, fibroblast proliferation, extracellular matrix secretion, and eventually fibrotic scar maturation (Kologrivova et al., 2021). During the scar proliferation phase, subpopulations of monocytes and macrophages activate and recruit mesenchymal repair cells and primarily fibroblast-like cells by secreting growth factors (Frangogiannis, 2014). There is evidence that CFs originate from circulating progenitor stem cells (PSCs) recruited into the ventricular myocardium after birth and distribute throughout the normal myocardium as strands and sheets between myocardial muscle fibers and are critical effector cells in the scar repair process (Visconti and Markwald, 2006). In the normal physiological state, CFs account for 60%–70% of total cardiac cell numbers (Porter and Turner, 2009). They secrete collagen, which provides structural scaffolding for cardiomyocytes, coordinates myocardial motion, and mediates the onset of electrical activity (Bretherton et al., 2020). Under pathological conditions, fibroblasts transdifferentiate into myofibroblasts (MFBs) in response to various stimuli, including renin-angiotensin system activation, mechanochemical signaling, and release of transforming growth factor β (TGF-β), inflammatory factors (Frangogiannis, 2015; Han et al., 2022).

MFBs possess characteristics of both fibroblasts and smooth muscle cells, and secrete collagen to promote myocardial fibrosis. Meanwhile, these cells are analogous to smooth muscle cell contraction (as present in the vascular system), which can be modulated by circulating factors and neurohormones, including angiotensin II (van den Borne et al., 2010). Apoptosis of most repair cells indicates the end of the proliferative phase, and as the development of MI pathophysiology, the scar matures via a steady increase in collagen cross-linking (Frangogiannis, 2012). However, persistent MFBs differentiation and activation, as well as extracellular matrix (ECM) deposition, contribute to a decreased compliance of the myocardium (Umbarkar et al., 2021). On the other hand, progressive decline in the delivery of oxygen and nutrients induces atrophy and cell death in the cardiomyocytes, contributing to progressive acute left ventricular dilatation and, ultimately, dysfunction and heart failure (Gibb et al., 2020). Thus, controlling the fibrosis process and achieving a dynamic balance between pro-and anti-fibrosis are of great significance for post-infarction repair. Given the complexity of post-infarction cardiac remodeling, this review focuses on two significant aspects: inflammatory response and fibrotic scar repair.

EVs are nanoscale lipid particles generated by the endosomal system of eukaryotes and secreted into the extracellular environment (Borges et al., 2013; van der Pol et al., 2014; Yanez-Mo et al., 2015; Zaborowski et al., 2015). Currently, there is still no exact criteria on the nomenclature of EVs. Various names are used, such as exosomes, microparticles, MVs, ABs. Remarkably, the nomenclature of “extracellular vesicles” proposed by Chistiakov mainly used in this review (Chistiakov et al., 2015), which means that EVs are typically categorized subsets by their size, formation, marker proteins, release mechanisms, and lipid composition, including three types of plasma membrane exfoliated vesicles: exosomes (30–150 nm), MVs (1,000–1,000 nm), and ABs (500–2,000 nm) (Liu H et al., 2021). Exosomes are phospholipid bilayers membrane-enclosed vesicles (Pegtel and Gould, 2019), which were initially discovered in sheep reticulocytes in 1983 and then were named “exosomes” by Johnstone in 1987 (Pan and Johnstone, 1983; Johnstone et al., 1987). Several studies have indicated that the inward budding of the early endosomal membrane forms early endosomes and then matures into late endosomes which are often packed with small intraluminal vesicles (ILVs) and evolve into multivesicular bodies (MVBs) (Ohayon et al., 2021). After a series of intracellular transport, the degradation of vesicles occurs when some MVBs fuse with lysosomes. While other MVBs release ILVs such as exosomes when fusing with the plasma membrane (Kowal et al., 2014; Villarroya-Beltri et al., 2016). These exosomes can be detected in diverse bodily fluids, such as breast milk, saliva, blood, urine (Pisitkun et al., 2004; Caby et al., 2005; Admyre et al., 2007; Palanisamy et al., 2010). Simultaneously, numerous studies suggest that a broad range of cell types, including cardiomyocytes, immune cells, progenitor cells, fibroblasts, and stem cells can generate exosomes (Zitvogel et al., 1998; Doyle and Wang, 2019).

MVs were first described by Peter Wolf in 1967 and are generated by the outward budding of plasma membrane (Wolf, 1967), and they are also the result of dynamic interaction between redistribution of phosphatidylserine (PS) and the remodeling of cytoskeletal proteins (Zwaal and Schroit, 1997; Leventis and Grinstein, 2010); proteins and phospholipids are distributed very heterogeneously and form microdomains within the membrane. Aminophospholipid translocases tightly control this asymmetric distribution of PS on plasma membranes. Moreover, flippase is a translocase that translocates PS from the outer leaflet to the inner leaflet of the membrane, while floppase transfers phospholipids from the inner to the outer leaflet of the plasma membrane (Zwaal and Schroit, 1997; Hugel et al., 2005). Immediately afterwards, actin-myosin interactions promote cytoskeleton contraction, aid cell membranes’ budding, and ultimately form MVs (McConnell et al., 2009; Muralidharan-Chari et al., 2009). The number of these generated MVs relies on the physiological state and microenvironment of the donor cells while consumed MVs depends on the physiological state and microenvironment of the recipient cells (Zaborowski et al., 2015).

These EVs can enter the recipient cells via fusing with cellular membranes; on the other hand, it also enters the recipient cells via different endocytic pathways, including phagocytosis clathrin-mediated endocytosis, caveolae, or lipid raft-mediated endocytosis (Feng et al., 2010; Tian et al., 2014; Costa Verdera et al., 2017; Hou and Chen, 2021). Moreover, classical intercellular adhesion molecules also mediate the binding of EVs to the target cells (Zhao et al., 2015); specifically, on the one hand, TIM family members (TIM1, TIM4) PS transmembrane receptors are used by target cells for exosomes entry (Miyanishi et al., 2007), on the other hand, exosomes derived from B cells containing a 2,3-linked dialkylated glycoprotein can be captured by lymph node and spleen CD169⁺ macrophages (Saunderson et al., 2014). At the same time, macrophages uptake exosome via C-type lectins expressed in macrophages and galectin-5 exposed to exosome (Barres et al., 2010). Meanwhile, multiple mechanisms have been demonstrated to be associated with regulating the biogenesis of EVs, especially the endosomal sorting complex required for transport (ESCRT) or non-ESCRT mechanisms (Assil et al., 2015). ESCRT consists of four core subunits (ESCRT-0; ESCRT-I; ESCRT-II; ESCRT-III), where ESCRT-0 mediates substrate recognition and sorting, ESCRT-I and ESCRT-II are critical for mediating endosomal membrane inward budding, and ESCRT-III is responsible for shearing the neck of the budding body, thereby orchestrating the formation of an inward budding vesicle of MVBs (Hurley and Hanson, 2010; Hanson and Cashikar, 2012; Tarasov et al., 2021). Considering the biological complexity of EVs and is susceptible to the environment, there are yet no established criteria to distinguish different types of EVs, which limits the development of related studies (Amosse et al., 2017) (Figure 1).

Initially, EVs were considered waste products released by cells. Later studies, however, demonstrated that EVs mediate the transmission of intercellular molecular biological information and play a crucial role in intercellular communication (Hessvik and Llorente, 2018; Harmati et al., 2021). Besides, EVs can transport bioactive cargoes, including RNA, DNA, proteins, and lipids (Chen F et al., 2020). Indeed, it both retains many of the biological properties of their parental cells and regulates recipient cells’ physiological or pathological processes (Xing et al., 2021). Of the three types of EVs, exosomes are derived from MVBs, which budding inward from a raft-like domain and, therefore, have a slightly different lipid content than the cell membrane. Exosomes are rich in cholesterol, sphingomyelin, glycerophosphocholine, and phosphatidylcholine (Laulagnier et al., 2004; Raposo and Stoorvogel, 2013; Janas et al., 2015), and membrane surface markers such as integrins, Flotillin 1, CD63, CD81, Alix, TSG101, and cell adhesion molecules (CAMs) (Lotvall et al., 2014). Due to its small size, protective lipid bilayer, and surface receptors, exosome can mediate long-distance, inter-tissue systemic crosstalk (Mathieu et al., 2019; Pelissier Vatter et al., 2021).

The lipid composition and markers of MVs depend mainly on the composition of their cell membrane and also show particular antigens concerning the membrane composition of the original cell. For example, T cell MVs carry CD4 or T cell receptors (Choudhuri et al., 2014). Monocyte-derived MVs show CD14, while CD31, CD34, CD51, CD62E, CD144 and CD146 expressed on endothelium-derived MVs (Koga et al., 2005). Microvesicular cholesterol and hyperphosphatidylserine expose a lipid composition different from that of exosomes. Addition, the shape and density of MVs are irregular as well as the surface does not have any tetrapeptide (Muralidharan-Chari et al., 2010; Choudhuri et al., 2014). These vesicles consist of a lipid bilayer and have mRNAs, miRNAs, biologically active lipids, metabolites, and protein in which surface phospholipid bilayer (Ratajczak and Ratajczak, 2020), it also expresses the number of transmembrane proteins, such as integrins and selectins as in the parental cell membrane (Bobrie et al., 2011; Raposo and Stoorvogel, 2013). However, MVs contain a large number of cytoplasmic and plasma membrane proteins, such as cytoskeletal proteins, heat shock proteins, and protein tetrapeptides that accumulate on the surface of the plasma membrane, which is 100-fold more concentrated in MVs than in cell lysates (Escola et al., 1998; Zoller, 2009; Di Vizio et al., 2012; Morello et al., 2013), and contribute significantly to intercellular communication (Cocucci et al., 2009). On the other hand, the function of MVs depends on the cell types from which they originate (Muralidharan-Chari et al., 2010). For example, immune cell-derived MVs are involved in inflammatory responses, while endothelial cell-derived MVs are related to blood vessels (Morel et al., 2004). In addition to this, the procoagulant properties of MVs were reported for the first time in 1946 by Chargaff and West and later confirmed by Wolf in 1967, who described them as “platelet dust” (Wolf, 1967; Morel et al., 2004).

In recent years, there have been concerns regarding the relationship between EVs and diseases, with numerous studies focusing on cancer (Prieto-Vila et al., 2021), Parkinson’s (D'Anca et al., 2019), infectious diseases (Rodrigues et al., 2018), kidney diseases (Thongboonkerd, 2019), and cardiovascular diseases, resulting in substantial influential outcomes. A great deal of research in cardiovascular disease suggests that EVs play an essential role in cardiac pathophysiology (Njock et al., 2015), and EVs of diverse origins are necessary for maintaining cardiac function and homeostasis via influencing and interacting with each other (Yu and Wang, 2019). These subgroups exhibit a wide range of functions, making them an important source of potential biomarkers for early diagnosis, therapeutic drug delivery systems, or vaccine production systems (Bordanaba-Florit et al., 2021).

Numerous studies have shown that EVs have similar biological properties to parental cells. Interestingly, however, multiple cells produce EVs after MI, including cardiomyocytes, immune cells, ECs, progenitor cells, fibroblasts, and stem cells (Fujita et al., 2019; Berezin and Berezin, 2020). The presence of pro-inflammatory M1 macrophages (M1-MØ) and reparative M2 macrophages (M2- MØ) as well as N1 (Ly6G⁺CD206^-) and N2 (Ly6G⁺CD206⁺) neutrophil phenotypes in the infarcted heart mean immune cells exhibit functions and phenotypic heterogeneity (Ma et al., 2016; Peet et al., 2020). N1 neutrophils are pro-inflammatory, with high expression of pro-inflammatory markers, such as TNF-α, IL-1b, macrophage inflammatory protein 1α (CCL3), and interleukin 12a (IL-12a), while anti-inflammatory Cd206 and interleukin 10 (IL-10) are highly expressed in N2 neutrophils. Similarly, monocytes differentiate into pro-inflammatory and anti-inflammatory. EVs of different origins and subtypes also have complex and diverse roles similar to their parental cells and play a dual role in post-infarction cardiac remodeling. These EVs maintain a dynamic balance between pro-and anti-inflammatory, pro-and anti-fibrotic. Thus, it is significant to investigate the involvement of EVs in post-infarction cardiac remodeling, providing new avenues to open up targeted therapeutic strategies.

Clinical applications of EVs are novel therapeutic modalities, including vaccines, diagnostic criteria, and drug delivery. The idea of using EVs as anti-tumor vaccines originated in the last century. Basic studies suggested that DEX can promote T-cell dependent antitumor effect, and phase I clinical trials (to vaccinate peptide-pulses DEX for patients with cancer) demonstrated that the feasibility and safety of inoculation of DEX (Escudier et al., 2005; Morse et al., 2005). Immediately after, Sophie et al. developed a second-generation DEX with enhanced immunostimulatory properties and produced large-scale IFN-γ-DEX vaccines while conducting phase II clinical trials (NCT01159288) under the guidance of Institut Gustave Roussy in France, in which DEX was administered to patients with non-small cell lung cancer with the aim of increasing progression-free survival (Viaud et al., 2011; Lener et al., 2015). In respiratory diseases, preclinical studies have established that MSC-Exos can ameliorate most of the pathological changes caused by lung infections. And a clinical study (NCT04602104) for treating acute respiratory distress syndrome (ARDS) with MSC-Exos Nebulizer is currently recruiting patients, this study explores a new approach to treat ARDS and assesses its safety by administering human mesenchymal stem cell exosomes (hMSC-Exos) aerosol inhalation to patients. It has also been shown that ExoFlo™, derived from allogeneic bone marrow mesenchymal stem cells, can reconstitute immunity, downregulate cytokine storm and restore oxygenation in patients with severe COVID-19, demonstrating the promise of ExoFlo for the treatment of COVID-19 (Sengupta et al., 2020). In renal disease, intra-arterial and intravenous administration of MSC-Exos to patients with grade III-IV chronic kidney disease in phase II/III clinical trials was shown to ameliorate inflammation and renal function. No adverse events associated with MSC-Exos administration were observed in subjects during the 1-year follow-up period (Nassar et al., 2016; Guo et al., 2020). In cardiovascular system diseases, a phase II randomized clinical trial of intravenous ischemia-tolerant MSCs (itMSCs) in patients with non-ischemic cardiomyopathy showed that single-dose of intravenous itMSCs was safe and well tolerated compared with controls, increasing the patient’s 6-min walk distance while eliciting systemic immunomodulatory effects associated with improved LVEF (Butler et al., 2017). Examples of these clinical trials showed the great therapeutic potential of EVs.

The complex properties of EVs make their specification and characterization difficult. Thus, in addition to controlling the final product by specification and characterization, the quality of EVs must be ensured by quality control of the raw material and regulation of the manufacturing process (Tsuchiya et al., 2022). EV manufacturing must be performed in accordance with Good Practice (GxP) regulations, which are a collection of quality guidelines and regulations designed to ensure that biological/medical products are safe, meet their intended use and follow quality processes in manufacturing, control, storage and distribution (Good Manufacturing, Good Laboratory, Good Distribution, Good Clinical, Good Scientific Practice) (Soekmadji et al., 2020). The biological activity of EV used as a therapeutic agent must be tested in a qualified bioassay, called a “potency assay" (Lener et al., 2015). EVs are subject to detailed guidelines for the clinical application and manufacture of novel biomedical products in the EU. In Australia, the government’s Therapeutic Goods Administration (TGA) office provides rules and guidelines related to the manufacture and use of therapeutic agents often adopted in EU rules. In the United States, EV-based therapeutics for human use are regulated by the Center for Biologics Evaluation and Research (CBER) within the Food and Drug Administration (FDA) (Lener et al., 2015). (Figure 3).

Post-infarction cardiac remodeling is a complex and diverse pathological process consisting of two main phases: inflammatory response and fibrotic scar repair. Sudden and substantial cardiomyocyte death triggers a vigorous inflammatory response and subsequently activated MFBs, which secrete collagen, leading to myocardial fibrosis and consequent scar formation. Moderate myocardial fibrosis plays a critical protective role, maintaining the structural integrity of the chambers and preventing cardiac rupture, while persistent myocardial fibrosis can lead to cardiac stiffness and diastolic dysfunction, eventually causing HF. The search for new measures and approaches that can attenuate the post-infarction inflammatory response as well as maintain the dynamic balance of fibrosis repair is particularly critical. EVs of different cellular origins play a dual role in the early post-infarction inflammatory response and the subsequent repair of fibrotic scars. During the early inflammatory phase, these vesicles are involved in both pro-inflammatory and anti-inflammatory responses, and therefore, by achieving effective control of the release of pro-inflammatory vesicles and the delivery of their cargoes is of great importance to contain the early adverse persistent inflammatory response after infarction. At the same time, these vesicles play a dual role of pro-fibrotic and anti-fibrotic effects in the subsequent fibrotic scar repair phase, a property that also shows the importance of maintaining the dynamic balance of post-infarction fibrotic repair by modulating EVs. Currently, research on targeted regulation of EVs in cardiovascular diseases has focused on drug pretreatment as well as engineered modifications.

Research associated with the intercellular delivery of functional nucleic acids and proteins by EVs has demonstrated their advantages as cargo carriers, such as low immunogenicity, high stability and biocompatibility, long cycle life, and ability to cross the blood-brain barrier. These properties make EVs an important endogenous carrier for delivering therapeutic drugs, however, the current research on extracellular vesicle drug delivery is mainly focused on cancer and neurological related diseases, while preclinical studies on cardiovascular diseases are rare. The reasons for this are limited by the isolation of endogenous vesicles, storage, mass production techniques, low efficiency of targeted drug delivery and cellular uptake, on the one hand, and the unknown biological distribution of drug-loaded vesicles in the individuals treated with them, on the other hand, which may lead to difficult challenges in managing the use of exosomes in standardized methods related to their isolation, quantification and outcome analysis. Currently, EVs were isolated by Polymer precipitation, Differential ultracentrifugation, Field-flow fractionation, and Gradient density ultracentrifugation. These methods always lacking in yield and purity. Distinct purification methods of EVs exist in relation to the physical or molecular characteristics of isolated EVs preparations and affect the results of downstream analysis. The best separation strategy for EVs is by applying different methods of isolation in order to achieve a desirable recovery and purity and report in detail about standardized approaches for isolation, this research is particularly important, especially in the context of promising clinical applications of EVs(Clos-Sansalvador et al., 2022). Second, drug loading cannot disrupt the membrane structure and content of EVs, and finding effective ways to load therapeutic drugs into these EVs remains a great challenge. Although, the use of EVs as drug delivery carriers is still in the developmental stage. However, with a deeper understanding of the physiological properties of EVs, improved isolation and drug delivery techniques for EVs, the understanding and conclusion of exosome-loaded drugs in other diseases (cancer, hepatitis, Parkinson’s disease, etc.) will help develop or expand future therapeutic approaches for post-infarction cardiac remodeling, mitigate the inflammatory response during post-infarction cardiac remodeling, precisely regulate the dynamic balance between pro- and anti-fibrosis, and ultimately the transition from basic research to clinical applications.