Mitochondrial dysfunction is a key contributor to cardiac injury and heart failure, and extracellular vesicles (EVs) have emerged as promising therapeutic agents due to their ability to deliver mitochondrial-targeted cargo. This review systematically maps the evidence on how EVs modulate mitochondrial dynamics—including fusion, fission, mitophagy, and biogenesis—in regenerative cardiology. We comprehensively searched PubMed, Scopus, and Web of Science up to September 2025 for original studies. A total of 48 studies were included, with most utilizing EVs from mesenchymal stem cells, induced pluripotent stem cells, or cardiac progenitors. The review found that EV cargo influences key pathways such as DRP1 and MFN2, restores mitochondrial membrane potential, reduces ROS accumulation, and improves cardiomyocyte survival. While engineered EVs showed enhanced specificity, a lack of standardized preparation and quantitative assessment methods remains a significant challenge. We conclude that EV-mediated mitochondrial modulation is a promising strategy for cardiac repair, but the field needs harmonized protocols, deeper mechanistic understanding, and improved translational readiness to advance beyond preclinical research. The future of this research lies in integrating systems biology and precision targeting.

Mitochondrial dysfunction is a pivotal contributor to cardiac disease progression, making it a critical target in regenerative interventions. Extracellular vesicles (EVs) have recently emerged as powerful mediators of mitochondrial transfer and cardiomyocyte repair. This review highlights recent advancements in EV bioengineering and their applications in cardiac mitochondrial rescue, with a particular focus on EVs derived from induced pluripotent stem cell–derived cardiomyocytes (iPSC-CMs). Drawing upon a growing body of preclinical evidence, we examine the mechanisms of mitochondrial content delivery, EV uptake dynamics, and comparative bioenergetic restoration outcomes across EV sources. Special emphasis is placed on therapeutic outcomes such as adenosine triphosphate (ATP) restoration, reactive oxygen species (ROS) modulation, and improvements in contractility and infarct size. The convergence of mitochondrial biology, stem cell-derived EV platforms, and engineering innovations positions mitochondria-enriched EVs as a promising non-cellular regenerative modality for cardiovascular disease.

The demand for mass production of induced pluripotent stem cell-derived cardiomyocytes (iPSC-CMs) is escalating, driven by their potential to revolutionize cardiac regenerative therapies. The development of large-scale production protocols for iPSC-CMs is crucial to attain their therapeutic potential, enabling the treatment of millions of patients’ worldwide suffering from cardiovascular diseases. However, the scalable production of iPSC-CMs hinges on overcoming several critical challenges, including cellular differentiation and maturation. In pursue of tackling these challenges, researchers are investigating novel strategies such as prolonged culture periods, mechanical stimulation, and co-culture with supporting cell types. Overcoming these challenges is essential for unlocking the full potential of iPSC-CMs and paving the way for a new era in cardiac regenerative medicine. In this review, following topics are covered: (1) improvement of differentiation and maturation of iPSC-CMs and (2) scalable production of iPSC-CMs.

Background and Objectives: Induced pluripotent stem cell-derived cardiomyocytes (iPSC-CMs) have revolutionized cardiac research by providing patient-specific models for studying arrhythmias. However, their clinical application is hindered by arrhythmogenic risks associated with grafted iPSC-CMs. This review aims to delineate the current limitations in iPSC-CM-based arrhythmia modeling and explore emerging therapeutic strategies to mitigate these risks. Materials and Methods: A comprehensive literature review was conducted, focusing on studies published in the last two decades that address the electrophysiological characteristics of iPSC-CMs, their arrhythmogenic potential, and therapeutic interventions. Sources include peer-reviewed journals, clinical trial reports, and recent advancements in stem cell technology. Results: Findings indicate that while iPSC-CMs offer a promising platform for arrhythmia modeling, challenges such as cellular heterogeneity, immaturity, and proarrhythmic potential persist. Advancements in maturation protocols, co-culture systems, and gene editing techniques have shown promise in enhancing the safety profile of iPSC-CMs. Conclusions: Addressing the arrhythmogenic risks associated with iPSC-CMs requires a multifaceted approach, including improved differentiation protocols, maturation strategies, and therapeutic interventions. Continued research is essential to translate these models into safe and effective clinical applications.

Human iPSC-derived cardiomyocytes (iPSC-CMs) exhibit fetal-like mitochondrial networks and limited oxidative metabolism, constraining their translational utility. The key bottleneck is mitochondrial immaturity, resulting from blunted PGC-1α–NRF1/2–TFAM axis activation and insufficient nuclear–mitochondrial coordination, rather than sarcomeric or electrophysiological immaturity alone. This review synthesizes genome-guided interventions (CRISPRa and mtDNA editing) and complementary environmental strategies—including metabolic substrate switching, electromechanical stimulation, and extracellular vesicle (EV)-mediated mitochondrial transfer—to drive mitochondrial biogenesis and maturation in iPSC-CMs. We systematically reviewed studies (2005–2025) targeting (1) key regulators of mitochondrial biogenesis (PGC-1α, NRF1/2, TFAM), (2) CRISPR-based transcriptional activators/repressors and mtDNA editors (DdCBE, mitoTALENs), and (3) maturation approaches such as metabolic conditioning, electromechanical stimulation, 3D tissue culture, and EV-mediated mitochondrial transfer. CRISPRa-mediated activation of PGC-1α, NRF1, and GATA4, combined with mtDNA base editors, enhances mitochondrial mass and OXPHOS function, while integration with environmental maturation strategies further promotes adult-like phenotypes. Integrative approaches that combine genome-guided interventions (CRISPRa, mtDNA editing) with environmental maturation cues yield the most adult-like iPSC-CM phenotypes reported to date. CRISPR-guided mitochondrial biogenesis thus represents a frontier for producing metabolically competent, structurally mature iPSC-CMs for disease modeling and therapy. Remaining translational challenges include efficient mitochondrial delivery, metabolic homeostasis, and multi-omics validation. We propose standardized workflows to couple nuclear and mitochondrial editing with maturation strategies.