cells
Review
Microvascular Leakage as Therapeutic Target for Ischemia and
Reperfusion Injury
Jan Andreas Kloka 1 , Benjamin Friedrichson 1 , Petra Wülfroth 2 , Rainer Henning 3 and Kai Zacharowski 1, *
Citation: Kloka, J.A.; Friedrichson, B.;
Wülfroth, P.; Henning, R.;
Zacharowski, K. Microvascular
Leakage as Therapeutic Target for
Ischemia and Reperfusion Injury.
Cells 2023, 12, 1345. https://doi.org/
10.3390/cells12101345
Academic Editor: Jessica Filosa
Received: 30 March 2023
Revised: 3 May 2023
Accepted: 7 May 2023
Published: 9 May 2023
Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
Cells 2023, 12, 1345. https://doi.org/10.3390/cells12101345
1 Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt,
Goethe University, 60590 Frankfurt, Germany; benjamin.friedrichson@kgu.de (B.F.)
2 F4 Pharma, 1060 Vienna, Austria
3 Accella Advisors, 8737 Uetliburg, Switzerland
* Correspondence: kai.zacharowski@kgu.de
Abstract: Reperfusion injury is a very common complication of various indicated therapies such as
the re-opening of vessels in the myocardium or brain as well as reflow in hemodynamic shutdown
(cardiac arrest, severe trauma, aortic cross-clamping). The treatment and prevention of reperfusion
injury has therefore been a topic of immense interest in terms of mechanistic understanding, the explo-
ration of interventions in animal models and in the clinical setting in major prospective studies. While
a wealth of encouraging results has been obtained in the lab, the translation into clinical success has
met with mixed outcomes at best. Considering the still very high medical need, progress continues to
be urgently needed. Multi-target approaches rationally linking interference with pathophysiological
pathways as well as a renewed focus on aspects of microvascular dysfunction, especially on the role
of microvascular leakage, are likely to provide new insights.
Keywords: reperfusion injury; capillary leak; edema; organ protection; clinical outcome
1. Introduction
Cardiovascular diseases (CVD) continue to be the most important cause of illness and
mortality worldwide. In 2020, it was estimated that 19.1 million deaths could be attributed
to CVD globally; 85% of these deaths were due to acute myocardial infarction (AMI) or
stroke [1]. Fortunately, an overall decline of acute CV events at a rate of 2–4%/year can be
observed in industrialized countries, which can be attributed to the lowering of cholesterol
levels and to a number of lifestyle factors. Case fatality has decreased at a similar rate due
to continuous improvements in treatment procedures and post-treatment care [2]. Since
the predominant cause of acute CV events is the occlusion of a coronary or cerebral artery,
immediate revascularization by mechanical means (PCI and stenting) or thrombolysis is
the treatment of choice. Patients with severe infarcts are now able to survive. However, as
a consequence, an increase in post-MI heart failure is observed because of the weakened
myocardium [3,4].
The sudden restoration of blood flow to the ischemic tissue can lead to further
tissue damage as an unintended consequence. This phenomenon has been termed is-
chemia/reperfusion injury (IRI); it is now accepted to be a major contributor to the extent
of the final lesion and therefore to clinical outcome [5]. Ischemia/reperfusion injury also
plays an important role in poor clinical outcome in situations of multiple-organ or whole-
body ischemia. Full recovery after cardiac arrest and resuscitation continues to be quite
poor, and IRI contributes importantly to multi-organ malfunction [6–8]. In recovery from
severe trauma with major bleeding and reperfusion it has been shown that IRI is an impor-
tant factor [9]. Major thoracic-abdominal surgery with aortic cross-clamping may lead to
severe cardiac, renal, hepatic, limb, spinal cord and pulmonary problems due to IRI occur-
rence [10,11]. For all these reasons, the prevention of the damage caused by reperfusion has
become a target of intense research, both experimentally and clinically, in order to further
https://www.mdpi.com/journal/cells
Cells 2023, 12, 1345 2 of 21

improve outcome. A recent query in PubMed for “ischemia reperfusion injury” resulted in
71,153 entries, with the vast majority of papers having been published since the mid-1980s.
This review will discuss mechanistic aspects of ischemia/reperfusion injury in the
heart and the CNS, but will also touch upon other organs (kidney, lung, liver) where the
occurrence is well established as a cause of poor organ function following transplantation.
We will also discuss the translation of these pathophysiological findings from animal
studies into clinical outcomes. So far, the available data have not allowed clear treatment
guidelines to be established, but trends are emerging.
A wealth of mechanistic studies has revealed important pathophysiological elements
contributing to IRI, which have been reviewed extensively [5,12–14]. A focus of this review
will be on microvascular dysfunction and capillary leakage as a major contributor to IRI as
well as experimental and clinical evidence of its pathophysiological relevance.

2. Pathophysiology of Ischemia/Reperfusion Injury

Ischemia is defined as a lack of oxygen supply in tissues (hypoperfusion). Hypoperfu-
sion leads to a vulnerable state of the affected tissue. Several mechanisms and mediators
play a role in the response of the hypoxic cells to reperfusion. Oxygen free radicals, intra-
cellular calcium excess, endothelial and microvascular dysfunction and altered cellular
metabolism have all been demonstrated to play a major role (Figure 1). The restoration of
blood flow to tissues that have been affected by the ischemia leads to the massive genera-
tion of reactive oxygen species (ROS) because of the impairment of antioxidative agents
during ischemia. This oxidative stress promotes endothelial dysfunction, DNA damage,
cell death via necrosis, apoptosis and ferroptosis and local inflammatory responses due
to the accumulation of leukocytes [15]. Early studies concentrated on IRI in the ischemic
myocardium in ST-elevated myocardial infarction (STEMI); a historical perspective of
myocardial IRI has been elegantly provided by Jennings [16], who was the first to describe
the phenomenon in dogs in 1960 [17]. While the focus of many studies has been on the
heart, it has become clear that reperfusion injury also plays an important role in the CNS
as a sequel of mechanical or thrombolytic recanalization after an ischemic stroke [18,19],
and in impaired organ function following the transplantation of the kidney [20], liver [21]
and lung [22]. There are a lot of similarities in mechanistic underpinnings in the different
organs, as the resulting injury affects both the end-organ cell compartment as well as the
respective microvasculature.

2.1. Myocardial IRI

In order to salvage as much ischemic myocardium as possible, it is mandatory to
achieve timely reperfusion, preferably by primary percutaneous coronary intervention
(PPCI). The unavoidable secondary damage caused by reperfusion has many pathophysi-
ological components. In the cardiomyocyte compartment, edema/sarcolemmal rupture,
calcium overload and subsequent hypercontraction, mitochondrial dysfunction with the
opening of the mitochondrial permeability transition pore (MPTP), caused by the forma-
tion of reactive oxygen species (ROS) leading to apoptosis and ferroptosis and proteolysis
by caspases and calpain, have all been well described [23]. In coronary circulation, mi-
croembolization through excessive platelet aggregation and accrued plaque debris and
impaired vasomotion [24] cause no-reflow [25,26], which is observed in ~35% of all STEMI
patients. No-reflow and capillary rupture and subsequent hemorrhage are highly pre-
dictive for adverse clinical outcome [27,28]. Importantly, the disruption of endothelial
integrity [29] leads to the extravasation of fluid and macromolecules as well as the ex-
travasation of leukocytes with tissue inflammation caused by the release of inflammatory
cytokines [30]. The contribution of microvascular leakage and the evolution of myocardial
edema to post-MI outcomes has been largely underestimated and has only recently become
the focus of greater attention in the context of an integrative view of the function of the
coronary microvasculature in the refused myocardium [31]. Coronary capillaries are easily
compressed by interstitial edema and become hypoperfused. Cardiovascular magnetic
Cells 2023, 12, 1345 3 of 21

resonance imaging studies using T2 weighted imaging for the quantification of edema have
provided clear correlation of the extent of edema and hemorrhage with infarct size and
clinical outcome [32,33]. The extent of myocardial edema is therefore an important prog-
nostic criterion for STEMI outcome. The prevention of microvascular leak is an important
therapeutic target in reperfusion injury [34]. The mechanisms involved in this endothelial
disruption are discussed in more detail in Section 3.
Cells 2023, 12, x FOR PEER REVIEW
The lymphatic system plays an important role for edema resolution. Therefore, the
3 of 22
contribution to healing without adverse remodeling is receiving more and more atten-
tion [35].

Figure
Figure 1.1. Ischemia/reperfusion
Ischemia/reperfusion injury
injury affects
affectsthe
themyocardium
myocardiumandandthethe microvasculature.
microvasculature. Restora-
Restoration
tion of blood flow leads to production of reactive oxygen species, normalization of pH, release
of blood flow leads to production of reactive oxygen species, normalization of pH, release of calcium of
calcium and reduced availability of nitric oxide in the cardiomyocyte. These biochemical changes
and reduced availability of nitric oxide in the cardiomyocyte. These biochemical changes lead to
lead to myofibril contracture and MPTP opening in mitochondria, and eventually to necrosis, apop-
myofibril contracture and MPTP opening in mitochondria, and eventually to necrosis, apoptosis
tosis or necroptosis. Endothelial barrier disruption leads to extravasation of water and proteins from
or necroptosis.
the Endothelial
coronary vessels barrier
and edema, disruption
capillary leads to extravasation
compression of water
and microvascular and proteins
obstruction. from
Tissue in-
the coronaryis vessels
flammation and edema,
a consequence capillary
of leukocyte compression and microvascular obstruction. Tissue
diapedesis.
inflammation is a consequence of leukocyte diapedesis.
2.1. Myocardial IRI
2.2. IRI in the Brain
In order to salvage as much ischemic myocardium as possible, it is mandatory to
As in myocardial infarction, the restoration of blood flow is an important goal for the
achieve
treatmenttimely reperfusion,
of acute preferably
ischemic stroke. It has by primary
been clearly percutaneous coronarystroke
shown in experimental intervention
models
(PPCI). The unavoidable secondary damage caused by reperfusion
and in clinical studies that oxygen restoration may cause additional neuronal has many pathophys-
damage
iological
beyond thatcomponents.
elicited by Inthethe cardiomyocyte
ischemia compartment,
itself. Oxidative edema/sarcolemmal
stress, mitochondrial rupture,
impairment and
calcium overload and subsequent hypercontraction, mitochondrial dysfunction
the activation of platelets complement and importantly contribute to reperfusion injury [19]. with the
opening of the mitochondrial permeability transition pore (MPTP), caused by
Importantly, there is clear evidence that the disruption of the blood-brain barrier (BBB) with the for-
mation of reactive
the ultimate oxygenofspecies
consequence severe (ROS)
edemaleading to apoptosis
and eventual and ferroptosis
hemorrhagic and prote-
transformation plays
olysis by caspases and calpain, have all been well described [23]. In coronary
a decisive role in adverse outcome with accelerated neuronal destruction and neurological circulation,
microembolization
impairment [36,37].through excessive platelet aggregation and accrued plaque debris and
impaired vasomotion [24] cause no-reflow [25,26], which is observed in ~35% of all STEMI
2.3. IRI inNo-reflow
patients. Organ Transplantation
and capillary rupture and subsequent hemorrhage are highly predic-
tive for
Theadverse clinical outcome
transplantation [27,28].
of a donor Importantly,
organ is the bestthe disruption for
intervention of endothelial integ-
the treatment of
rity [29] with
patients leadsendto the extravasation
stage of Ischemia/reperfusion
organ failure. fluid and macromolecules asiswell
injury as the extravasa-
an inevitable compli-
tion of leukocytes with tissue inflammation caused by the release of inflammatory cyto-
kines [30]. The contribution of microvascular leakage and the evolution of myocardial
edema to post-MI outcomes has been largely underestimated and has only recently be-
come the focus of greater attention in the context of an integrative view of the function of
the coronary microvasculature in the refused myocardium [31]. Coronary capillaries are
Cells 2023, 12, 1345 4 of 21

cation in any organ transplantation due to the procedures involved in procuring, storing,
transporting and implanting the donor organ, which lead to the (temporary) disturbance of
oxygen supply. As there continues to be a shortage of viable donor organs, it is imperative
to minimize the procedural organ damage, and the prevention of IRI is a major component
of this effort in order to be able to use extended criteria organs and alleviate the shortage to
a maximum extent. From a clinical standpoint, ischemia/reperfusion injury is connected
to postponed graft function, acute and chronic rejection, as well as chronic issues with
graft functionality.
As in myocardial and CNS IRI, multiple molecular pathways have been found to be
actively involved including the activation of cell death programs, the impaired function
of the endothelium, transcriptional reprogramming, as well as the activation of both the
innate and adaptive immune systems. At the cellular and tissue levels, energy metabolism,
mitochondria and cellular membranes are all critically involved. Microvascular dysfunction
with increased vascular permeability and inflammation caused by the recruitment of
polymorphonucleated cells (PMNs) has been found to play a decisive role. The underlying
mechanisms of microvascular dysfunction in the kidney have been reviewed [20,38].
In preserved and transplanted lungs, perivascular and alveolar edema were found
to be caused by morphologic alterations of ECs resulting in monolayer discontinuities
followed by cell detachment. These alterations were present after the storage period and
became more marked with the restoration of blood flow on revascularization [39].
In liver transplantation, IRI is initiated by damage to hepatic sinusoidal endothelial
cells and the disruption of microcirculation during ex vivo preservation, which is exacer-
bated by reperfusion during the implantation surgery. It has been clearly demonstrated
that the dysfunction of hepatic microcirculation is strongly correlated with early allograft
dysfunction [40].

2.4. IRI Following Global Ischemia after Cardiac Arrest

Out of hospital cardiac arrest affects >300,000 patients annually in the US alone.
Despite many improvements in treatment, especially in the rate of spontaneous circu-
lation, the prognosis continues to be dire with in-hospital mortality exceeding 50% [1].
Ischemia/reperfusion injury is a frequent consequence of the successful resuscitation of
patients suffering from a spontaneous cardiac arrest. The ensemble of pathophysiological
effects is referred to as post-cardiac arrest syndrome (PCAS). These complications affect all
organs, since the spontaneous restoration of blood flow affects all organs suffering from
oxygen deprivation during the arrest. The current status of epidemiology, pathophysiology,
treatment and prognostication has been reviewed in an ILCOR Consensus Statement and
other summary reports [41,42]. It has been demonstrated that therapeutic hypothermia in
particular is a valid strategy to improve outcome [43]. Therapeutic strategies employed
for the improvement of the clinical outcome of patients with acute myocardial infarction
may also benefit patients with PCAS. For instance, post-conditioning maneuvers have
demonstrated benefits in a porcine model [44].

3. Microvascular Dysfunction and Capillary Leakage in IRI

A monolayer of endothelial cells covers the luminal surface of all blood vessels in
the human body, which covers a surface area of greater than 1000 m2 [45]. It plays an
important role in a significant number of physiological functions, including vascular tone,
permeability for fluid, macromolecules and cells between the vascular lumen and tissue,
as well as coagulation and angiogenesis. The disturbance of the endothelial function
contributes significantly to many cardiovascular diseases [46,47].
Since the barrier function of the endothelial layer and its disruption are critically
involved in IRI, it is important to understand the molecular constituents of the endothelial
barrier and their regulation. This allows the identification of potential therapeutic targets
that prevent the disruption of endothelial junctions and thereby reduce or prevent IRI [48].
Cells 2023, 12, 1345 5 of 21

The junction between neighboring endothelial cells contains several macromolecular

complexes that contribute to the limited exchange of fluid, molecules and cells during
normal hemostatic conditions.
The central structural and functional component of the adherens junction is vascular
endothelial (VE)-cadherin, which is uniquely expressed in endothelial cells. It forms
homophilic interactions between juxtaposed cells. It forms multicomponent complexes
with several cytoplasmatic proteins, a very important one being with p120 catenin, which
stabilizes VE-cadherin in the plasma membrane. α, β and γ-catenins anchor VE-cadherin
to the actin cytoskeleton [49]. The stability of the intercellular VE-cadherin complexes is
critically dependent on the activation state of the actomyosin skeleton of the endothelia
cell. As demonstrated by Yang et al., VE-cadherin levels are reduced in the infarcted
myocardium, with the lowest levels found in no-reflow sections [50]. Under steady state
conditions, the actomyosin bundles form thick cortical bands that stabilize the adherens
junction. Factors that increase permeability induce actin remodeling and the formation of
Cells 2023, 12, x FOR PEER REVIEW
radial stress fibers, which promote the re-localization of VE-cadherin complexes6 to of 22
focal
junctions and facilitate their disruption, leading to increased permeability (Figure 2A).

(A)

(B) (C)
Figure 2. (A) under resting condition, the endothelial barrier is stabilized by attachment of VE-cad-
Figure 2. (A) under resting condition, the endothelial barrier is stabilized by attachment of VE-
herin to thick cortical bands of actin fibers. (B) upon stimulation with danger signals, the actomyosin
cadherin to thick
cytoskeleton cortical bands
is re-arranged of formation
with the actin fibers. (B) upon stimulation
of transcellular stress fibers.with danger signals,
The contraction of my-the
actomyosin cytoskeleton is re-arranged with the formation of transcellular stress fibers.
osin causes a disruption of the homotypic complexes of VE-cadherin and an opening of the adherens The contrac-
tion of myosin
junction. causes
(C) Rho a disruption
A and Rac 1 playofathe homotypic
central complexes
role in this process.ofUpon
VE-cadherin and an opening
GPCR activation of the
by various
ligands, RhoA is transformed into its GTP binding form, which can activate Rho-associated
adherens junction. (C) Rho A and Rac 1 play a central role in this process. Upon GPCR activation by kinase
(ROCK),
various whichRhoA
ligands, phosphorylates myosin
is transformed light
into chainbinding
its GTP leadingform,
to actomyosin
which cancontraction. The RhoA
activate Rho-associated
activity is functionally opposed by Rac1 (modified from [48]).
kinase (ROCK), which phosphorylates myosin light chain leading to actomyosin contraction. The
RhoA activity is functionally opposed by Rac1 (modified from [48]).
Another factor that drives the stability of the EC adherens junction is the phosphor-
ylation state of VE-cadherin. Phosphorylation at tyrosines 658 and 731 destabilizes bind-
Several lines of evidence point to the small GTPase of the Rho family as critical
ing to p120 and β-catenin, and phosphorylation at tyrosine 685 and serine 665 induces VE-
nodes in the regulation of endothelial contractile states. More specifically, the balance
cadherin internalization and barrier disruption [53]. The tyrosine phosphorylation of VE-
of the activation of RhoA and Rac1 is a main driver of permeability [51]. Even though
cadherin and therefore barrier stability is regulated by vascular endothelial protein tyro-
this interplay is complex depending on the upstream stimulus, in most circumstances the
sine phosphatase (VE-PTP) (Figure 2B) [54].
activation of RhoA leads to stress fiber formation and actomyosin contraction, whereas Rac1
Very important for the regulation of endothelial barrier function is the angiopoi-
activation is correlated with the assembly of junctions between ECs and the stabilization of
etin/TIE2 pathway. An important role of this system has been clearly demonstrated [55].
cortical actin
The most bundles
relevant [52]. of the angiopoietin protein family are angiopoietin 1 (Ang1)
members
and angiopoietin 2 (Ang2). Angiopoietin 1 is the natural ligand of the TIE2 receptor, which
importantly contributes to maintaining the integrity of the microvascular endothelial bar-
rier [56]. Angiopoietin 1 has been found to protect the heart against IRI by regulating VE-
cadherin phosphorylation via facilitated binding between SH2 domain-containing phos-
phatase (SHP2) or receptor protein tyrosine phosphatase µ (PTPµ) [57]. Furthermore, it
Cells 2023, 12, 1345 6 of 21

Another factor that drives the stability of the EC adherens junction is the phosphoryla-
tion state of VE-cadherin. Phosphorylation at tyrosines 658 and 731 destabilizes binding
to p120 and β-catenin, and phosphorylation at tyrosine 685 and serine 665 induces VE-
cadherin internalization and barrier disruption [53]. The tyrosine phosphorylation of
VE-cadherin and therefore barrier stability is regulated by vascular endothelial protein
tyrosine phosphatase (VE-PTP) (Figure 2B) [54].
Very important for the regulation of endothelial barrier function is the angiopoi-
etin/TIE2 pathway. An important role of this system has been clearly demonstrated [55].
The most relevant members of the angiopoietin protein family are angiopoietin 1 (Ang1)
and angiopoietin 2 (Ang2). Angiopoietin 1 is the natural ligand of the TIE2 receptor,
which importantly contributes to maintaining the integrity of the microvascular endothelial
barrier [56]. Angiopoietin 1 has been found to protect the heart against IRI by regulating
VE-cadherin phosphorylation via facilitated binding between SH2 domain-containing phos-
phatase (SHP2) or receptor protein tyrosine phosphatase µ (PTPµ) [57]. Furthermore, it
interacts with the integrin-β1/ERK/caspase-9 pathway in cardiomyoctes [57]. In a mouse
IRI model, treatment with Ang1 improved myocardial function [57]. On the contrary, Ang2
is a significant biomarker of myocardial infarction [58]. It has been shown to act as an
antagonist to Ang1 at the TIE2 receptor [56] and exacerbates cardiac hypoxia and inflam-
mation after myocardial ischemia by promoting pericyte detachment, vascular leakage,
increased adhesion molecular expression, the degradation of the glycocalyx and extra-
cellular matrix and enhanced neutrophil infiltration in the infarct border area [59]. The
overall activity of the Ang1/Ang2/TIE2 system is in addition rheostatically controlled by
the dephosphorylating activity of VE-PTP [60,61].
Another important factor influencing endothelial barrier integrity is sphingosine
1 phosphate (S1P) via interaction with its type 1 receptor (S1P1) in endothelial cells [62].
Sphingosine 1 phosphate is a lysosphingolipid found in the HDL fraction in blood and
also in red blood cells. Together with Ang1, S1P was found to be sufficient to promote
endothelial barrier function. Sphingosine 1 phosphate sustains the endothelial barrier
through increased homotypic VE-cadherin binding and the transportation of claudin 5
and other junctional proteins to the cell periphery [63]. It was also found to reduce IRI by
promoting the phosphorylation of the gap junction protein connexin43 [64]. A positive
effect of S1P was also identified in cerebral IRI, since endothelial signaling counteracts
infarct expansion in a mouse model [65].
An interesting protein, which has been shown to protect the endothelial barrier, is
the heat shock protein HSPA12B, the expression of which is restricted to the endothelial
cell. In a model of temporary coronary occlusion in mice, HSPA12B was shown to reduce
infarct size by the preservation of barrier integrity. This was achieved by attenuating the
IRI-induced reduction in the expression of the tight junction protein ZO-1 and the activation
of the PI3K/Akt/mTOR pathway in ECs [66].
Several lines of evidence point to microvascular leakage as an important contributor
to IRI in myocardial infarction [34,67], stroke [68] and acute kidney injury [69], with
the formation of edema as a pathophysiological hallmark. The prevention of excessive
microvascular permeability is therefore a very valid target for pharmaceutical intervention.

4. Therapeutic Approaches
Pathophysiological studies identified a very significant number of targets, which
could be addressed for the prevention or treatment of IRI. Many studies explore the
beneficial influence of the conditioning of the ischemic tissue on physiological pathways
(pre-, post- and remote conditioning) [70] and on influencing salvage pathways (RISK [71]
and SAFE [72]) and mitochondrial stability [73] under reperfusion conditions. These
approaches have been extensively reviewed elsewhere [74].
Cells 2023, 12, 1345 7 of 21

4.1. Experimental
It has been convincingly demonstrated that myocardial [63] and cerebral edema [75]
constitute a major factor determining the extent of reperfusion injury. Therefore, the phar-
macological prevention of increased microvascular endothelial permeability becomes a
valid approach to prevent and treat IRI. A significant number of studies pursued this
approach [76]. A highly interesting molecule is FX06, which constitutes the 28-mer peptide
Bβ15-42. This peptide is constitutively liberated by the plasmin degradation of cross-linked
fibrin [77–79]. It has been shown to reduce or prevent IRI in models of rodent and porcine
myocardial ischemia and reperfusion, septic and hemorrhagic shock in rodents and pigs, re-
suscitation after cardiac arrest, in acute kidney injury and in kidney [80], lung [81], liver [82]
and heart transplantation [83]. In acute transient LAD ligation in rats with 2 h reperfusion,
infarct size was reduced by 50% [84], which was found to be comparable to ischemic
preconditioning and superior to a CD18 MAb and the C5a antibody pexelizumab [85]. Scar
formation after 30 days of reperfusion was also significantly reduced. In acute and chronic
coronary ligation in pigs, this effect could be reproduced [86]. In acute and sub-chronic
porcine models of global ischemia/reperfusion and hemorrhagic shock, FX06 was not
only cardio-protective, but also reduced pulmonary, liver and small intestine damage and
improved neurological recovery [87,88]. In rodent models of cardiopulmonary resusci-
tation, FX06 was demonstrated to improve survival and neurocognitive recovery; these
effects could be attributed to the amelioration of capillary leakage [89]. The administration
of FX06 at different time points in a mouse model of acute kidney injury elicited by the
clamping of the renal artery for 30 min followed by reperfusion significantly reduced
endothelial activation and lowered the tissue infiltration of neutrophils as well as tissue
levels of neutrophil gelatinase-associated lipocalin (NGAL) [90–92]. Ischemia/reperfusion
injury was significantly attenuated in a rat cardiac transplant model when FX06 was added
to the cardioplegic solution. Treated animals showed significantly less myocardial necrosis
and decreased values of cardiac troponin, a reduced number of infiltrating leukocytes
and superior cardiac output [83]. In a murine allograft renal transplant model, FX06 im-
proved the survival of recipients during the 28-day follow-up (60% versus 10%). Treatment
decreased leukocyte infiltration, the expression of endothelial adhesion molecules and
proinflammatory cytokines. Treatment significantly attenuated allogenic T cell activation
and reduced graft rejection. Moreover, FX06 significantly reduced tubular epithelial damage
and apoptosis [80]. Finally, in models of bacterial sepsis [93] and viral infections (Lassa [94],
mouse thrombocytopenia syndrome virus [95] and Dengue [96]), which are known to be
accompanied by severe microvascular leakage, FX06 was demonstrated to improve survival
and hemodynamic changes; these effects could be attributed to the stabilization of the
endothelial barrier.
The mechanism of action by which FX06 stabilizes the endothelial barrier has been
thoroughly studied by several groups. FX06 competes with the binding of the fibrin E1
fragment to VE-cadherin and thereby prevents the dissociation of intercellular VE-cadherin
complexes [84]. It was also shown that the transmigration of leukocytes was prevented in
this way [84]. The compound rebalances the activation state of RhoA/Rac1 (reducing RhoA
and increasing Rac 1 activity) in favor of endothelial cell junction stability by counteracting
stress fiber formation via the prevention of myosin light chain phosphorylation. This is me-
diated by the dissociation of the src-family kinase Fyn, which dissociates from VE-cadherin
at adherens junctions upon the exposure of endothelial cells to the peptide. Following
that, Fyn binds with p190RhoGAP and hinders the activation of RhoA. Furthermore, the
prevention of endothelial cell contraction also involves FAK, as the peptide causes the
diffuse distribution of FAK in the cytosol instead of the localization of FAK at the tip of
stress fibers [96]. The outside-in signal that causes the Fyn dissociation from VE-cadherin
may be mediated by the binding of FX06 to the VLDL receptor [97,98].
CU06-1004, a pseudo-sugar derivative of cholesterol, is a novel compound under
investigation for multiple disease entities characterized by increased microvascular leakage.
It has been shown to reduce infarct size in models of rodent myocardial IRI by enhancing
Cells 2023, 12, 1345 8 of 21

vascular integrity, improving cardiac remodeling and suppressing edema and inflam-
mation [99]. It reduces cerebral edema and CNS IRI by suppressing blood-brain barrier
disruption and cerebral inflammation [100]. The amelioration of astrocyte end-feet swelling
contributes to this beneficial effect [101]. Via the modulation of colonic vessel dysfunc-
tion, experimental ulcerative colitis can be alleviated [102]. In a mouse model of diabetic
retinopathy, retinal vascular leakage is prevented [103,104]. CU06-1004 induces vascular
normalization and improves immunotherapy by modulating the tumor microenvironment
via cytotoxic T cells [105]. The compound has been shown to achieve its protective activity
via the cAMP/Rac/cortactin pathway, but the exact mechanism of signal transduction
remains to be fully elucidated [106].
The angiopoietin/TIE2 pathway has also been exploited to reduce and treat ischemia/
reperfusion injury. Angiopoietin-like protein 4 (ANGPTL4), a secreted 55-kDa protein that
is processed into 20-kDa and 35-kDa forms, was shown to be elevated following MI in
mice and humans. AGPTL4-deficient mice display (1) increased size of myocardial infarcts,
(2) increased no-reflow, (3) decreased vascular integrity through Src-dependent dissociation
of the VEGFR2/VE-cadherin complex and the subsequent destabilization of endothelial
adherens junctions and (4) increased hemorrhage and inflammation [107]. Recombinant
ANGPTL4 reduces no-reflow, hemorrhage and infarct size after myocardial infarction in
mice and rabbits [102]. It also attenuates intestinal barrier structure and function after
ischemia/reperfusion [108]. Interestingly, the traditional Chinese medicine Tongxinluo
is also active against myocardial IRI by stimulating the expression of ANGPTL4 [109].
Another approach to target the angiopoietin/TIE2 system was demonstrated by the appli-
cation of vasculotide, a short synthetic peptide (HHHRHSF), which binds with high affinity
to TIE2 and activates the receptor similar to Ang1. Vasculotide prevents IRI-induced renal
vascular leakage and congestion, improves renal function and recovery and significantly
attenuates mortality in an AKI model [110]. An angiopoietin-1 variant engineered for
higher potency and stability (COMP-Ang1) has been demonstrated to improve endothelial
dysfunction in various models. It preserved renal tubulary capillaries, reduced tubular
injury and decreased interstitial fibrosis in a rat acute kidney injury model [111]. It also
prevented IRI and reduced allograft rejection when donor hearts were pretreated with the
compound [112].
The specific small molecule VE-PTP inhibitor razuprotafib (AKB-9778) acts as an
indirect activator of TIE2 by alleviating negative receptor regulation. It has been shown to
stabilize microvascular integrity and is under investigation in diabetic macular edema [60].
Its application in myocardial and cerebral IRI has not been attempted yet.
The barrier-stabilizing effect of S1P1 has been the subject of several studies. For
instance, fingolimod (FTY720) has been shown to exert neuroprotective effects and BBB
stabilization in a rat stroke model [113]. SAR247799 is a G-protein selective S1P1 agonist
with endothelial protective effects in rats and pigs at doses that do not desensitize S1P1.
Preclinical studies with SAR247799 showed renal and coronary vasculature protective
effects when administered prior to an insult of ischemia/reperfusion-induced endothelial
injury [114]. The product is now in phase 2 clinical trials (see Section 4.2).
The PI3K/Akt/HIF-1α pathway, which is also a target for the EC heat shock protein
HSPA12B, interestingly is involved in the amelioration of hypoxia/reperfusion-induced
endothelial cell dysfunction by the opioid analog remifentanil [115].
Human relaxin-2 is a hormone structurally related to insulin with pleiotropic functions.
It has been shown to reduce the area of no-reflow primarily by the reduction of microvascu-
lar leakage via the stabilization of VE-cadherin in the endothelial adherens junction [116].
A family 1 receptor selective relaxin 2 analog (B7-33) was shown to reduce infarct size in a
mouse model. This effect is linked to the signaling of the MAP kinase pathway [117].
Imatinib (Gleevec® ) is a prototypical multi-kinase inhibitor. It has been shown to
reduce capillary leakage in multiple organ systems. Its main target Abl2 has been implicated
in the loss of microvascular integrity. Using Evans-blue staining, imatinib was shown to
reduce the formation of edema and hemorrhage in a rat cardiac infarct model [118]. It may
Cells 2023, 12, 1345 9 of 21

be worthwhile to investigate other kinase inhibitors for their influence on capillary leakage
since multiple kinase pathways are involved in the regulation of endothelial contractility.
Microvascular leakage also plays an important role in reperfusion injury subsequent
to ischemic stroke. Tetrahydrocurcumin (THC), a major bioactive constituent of turmeric,
has been demonstrated to abrogate brain edema and microvascular leakage in brain
parenchyma, most likely through an epigenetic mechanism [119].

4.2. Clinical
Myriads of experimental studies over the last few decades have shown evidence
of infarct size reduction and cardio-protection using a plethora of approaches, either by
various conditioning strategies or by pharmaceutical interventions. Many receptors and
signaling pathways that have been shown to potentially participate in myocardial IRI have
been used as targets. However, the translation of these encouraging results into clinical
outcomes has met with significant frustration. The results are equivocal at best in large,
controlled trials, which used hard clinical endpoints such as cardiac and overall mortality
and/or combined clinical outcomes (major adverse cardiovascular events, MACE). An
exception is coronary ischemic preconditioning in cardiac surgery, where a clinical benefit
on perioperative outcomes has been clearly demonstrated in a systematic review [120]. This
was corroborated in a prospective trial in 329 cardiac surgery patients, where a long-term
benefit was observed. All-cause mortality was assessed over 1.54 (SD 1.22) years and was
lower with remote ischemic preconditioning than without [121].
The concept of post-conditioning has received a lot of experimental and clinical atten-
tion. It is specifically attractive, since applying post-conditional maneuvers is independent
of the onset of ischemia and therefore conceptionally has broad utility. Post-conditioning
is achieved by multiple short periods of coronary occlusion subsequent to the opening
of the culprit coronary artery. The cardioprotective effects of post-conditioning were first
described in a model of coronary occlusion/reperfusion in dogs [122]. It has subsequently
been reproduced in other species such as rats [123] and rabbits [124]. Evidence points to-
wards interference with multiple triggers, effectors and pathways leading to the inhibition
of the opening of the PTP and delaying of cell alkalinization, reducing calcium accumulation
and oxidative damage as well as the attenuation of endothelial dysfunction [125,126].
A number of translational clinical trials that applied post-conditioning in the setting
of PCI for STEMI were initiated with somewhat conflicting results. Whereas some studies
showed evidence of a reduction in infarct size [127–130], at least one study had a negative
outcome [130]. In a recent large trial in STEMI patients undergoing PCI (DANAMI3-iPOST),
post-conditioning had no effect on a combination of all-cause mortality and hospitalization for
heart failure [131]. A follow-up trial (iPOST2; NCT03787745) is currently ongoing that does
not allow thrombectomy. Interestingly, it can be demonstrated that postconditioning is able to
reduce the formation of myocardial edema [132]. It is, however, not clear if this is a primary
effect of the post-conditioning maneuver or secondary to the reduction of infarct size.
In another large trial (LIPSIA CONDITIONING), post-conditioning was combined
with intrahospital remote preconditioning in patients with STEMI and PCI treatment. While
there was a statistically significant improvement of the myocardial salvage index in the
combined treatment group, post-conditioning alone had no effect. However, on long-term
follow up (median of 3.6 years) in the combined treatment group, major cardiac events
were reduced and this was driven by a reduction in new congestive heart failure [133].
Taking the available evidence together, it remains to be demonstrated that post-
conditioning maneuvers have a place in clinical practice in IRI prevention and, most
importantly, which patient group will benefit most from it.
The overall clinical situation is quite disappointing, as smaller trials in well-defined
populations gave hope for successful translation into improving longer-term clinical out-
comes. Table 1 provides a summary of the most important trials, which all failed. A very
detailed analysis of clinical trials performed so far has been discussed by Heusch and
Rassaf [134].
Cells 2023, 12, 1345 10 of 21

Table 1. Major negative clinical trials designed for demonstration of clinical benefit of preven-
tion/treatment of myocardial ischemia/reperfusion injury in heart surgery and PCI for STEMI.

Number Primary Endpoint

Study Name Type of Intervention Reference
of Patients And Outcome
Remote ischemic preconditioning in MACCE
ERICCA 1612 [135]
coronary artery bypass graft surgery Negative
Remote ischemic preconditioning MACCE
RIPHeart 1403 [136]
for heart surgery Negative
Combined cardiac death of
HF hospitalization 12 months
CONDI 2- Ischemic conditioning in STEMI Negative
5401 [137]
ERIC-PPCI patients undergoing PCI Combined cardiac death of
HF hospitalization 30 days
Negative
DANAMI-3- Ischemic Postconditioning During MACE
1234 [131]
iPOST PCI for Patients With STEMI Negative
6-month composite (all-cause
mortality,
Intravenous Bolus of Cyclosporin A
CYCLE 410 HF, cardiogenic shock) [138]
before PCI in patients with STEMI
Negative, (more events in CsA
group)
Composite of
death or rehospitalization or
Intravenous Bolus of Cyclosporin A worsening of HF, adverse LV
CIRCUS 970 [139]
before PCI in patients with STEMI remodeling
at 1 year
Negative
Intravenous bolus of MPTP blocker Infarct size (CK, TnI)
MITOCARE TRO40303 before PCI in patients 168 Negative (CK AUC0–72 h ) [140]
with STEMI TnI AUC0–72 h )
Infarct size by SPECT imaging
Adenosine infusion during and after
AMISTAD 236 at 5–12 days [141]
PCI for patients with STEMI
IS reduction by 31%
Adenosine infusion during and after MACE at 6 months
AMISTAD-II 2118 [142]
PCI for patients with STEMI Negative
30-day mortality
Bolus injection of anti-C5 antibody
Negative
APEX-AMI pexelizumab prior to PCI in patients 5745 [143]
MACE at 90 days
with STEMI
Negative
Infarct size (CK-MB AUC)
Negative (no difference in all
Infusion of delta-PKC inhibitor dose groups)
PROTECTION-
delcasertib during and after PCI in 1010 No difference in composite of [144,145]
AMI
patients with STEMI death, HF and serious
ventricular arrhythmias at
3 months
Infusion of GpIIb/IIIa MAb
MACE at 90 days
AIDA STEMI abciximab in patients with STEMI 2065 [146]
Negative
undergoing PCI
Single dose of erythropoietin within
Mean LVEF after 6 weeks
HEBE III 3 hrs after PCI in patients with 529 [147,148]
Negative
STEMI
Cells 2023, 12, 1345 11 of 21

Several authors have reflected on the reasons for this poor translation of promising
experimental results from animal studies [5,13,23,134,145,149–157]. In these detailed analy-
ses, some consensus has been achieved. Clearly, there are major differences in the setting of
animal studies vs. broad clinical application in patients. The pathophysiological mecha-
nisms, which in their totality determine the final outcomes of myocardial infarction and
reperfusion intervention, form a complex network. In order to evaluate the contribution
of a presumed target or pathway, however, they are usually studied in isolation. This
reductionist approach, even though required to provide robust data, which by nature
neglects the interactions with other pathways, does not usually take these interactions into
account. Furthermore, experimental approaches are usually performed in young healthy
animals, whereas patients usually have a long history of atherosclerotic lesions, which
eventually precipitate the coronary obstruction.
There is ample clinical evidence that the efficacy of cardioprotective treatment modal-
ities is further limited in the presence of comorbidities (hyperglycemia, hypertension,
hyperlipidemia). Advanced patient age also has negative effects on their efficacy [158].
These comorbidities affect changes in signaling pathways, which may have an influence on
the development of IRI itself and on the response to therapeutic interventions. Diabetic
patients have an increased susceptibility to IRI and lose response to ischemic conditioning
maneuvers. This is likely due to increased baseline oxidative stress and an impairment of
pathways protecting the myocardium from cell death [159]. Hypertension has been demon-
strated to negatively impact cardioprotection. For instance, hearts from spontaneously
hypertensive rats develop larger infarcts after coronary occlusion and are less reactive to
postconditioning [160,161]. This is also observed in aged animals; this has been linked to
changes in gene and protein expression, signal transaction cascades and deterioration in
mitochondrial function [162]. Even though the influence of female hormones on suscepti-
bility to ischemic heart disease is well known, the existence of a gender difference in the IRI
response is unclear and requires further investigation [163]. In order to improve the success
of new development products for cardioprotection, appropriate animal models must be
employed that include observations on these confounding influences [164]. Moreover,
patient selection in clinical trials is critical to avoid the dilution of clinical efficacy signals
by confounding factors [134,149]. In addition, patients usually have several co-medications
(e.g., antihypertensives, statins and anticoagulants) [165–167], which may have confound-
ing effects, as do anesthetics that are used during CABG, for which a conditioning response
has been proposed [168,169]. Most clinical trials have been performed in academic centers,
which provide highest quality care. For this reason, the post-intervention event rate in
clinical trials is significantly lower than in a broader population. These improvements in
standard care make it much harder to detect a protective contribution of an intervention
and require very large clinical trials.
Most large studies have concentrated on the protection of cardiac myocytes from
the consequences of ischemia and reperfusion. In smaller proof-of-concept trials, infarct
size fairly early after reperfusion was therefore used as the primary endpoint. However,
the long-term correlation with post-infarct remodeling is far from clear; this may have an
important impact on the longer-term outcome. Finally, the contribution of microvascular
impairment in the IRI processes has received a lot less attention, and some authors suggest
putting more emphasis on microcirculation as a target for cardio-protection [25,170–174].
Microvascular obstruction and capillary compression by myocardial edema caused by the
loss of endothelial function, which result in no-reflow, have been clearly correlated with
infarct size and clinical outcome [173].
The prevention of microvascular leakage has rarely been considered clinically for
the reduction of IRI. The translation of the preclinical effects in leak reduction achieved
with multiple experimental drugs should become a priority. It will be of great interest
to investigate those compounds that have been demonstrated to stabilize endothelial
integrity. A few clinical trials with such agents have been performed or are underway.
The fibrin-derived peptide FX06 has been investigated in the F.I.R.E. trial in 234 patients
Cells 2023, 12, 1345 12 of 21

undergoing PCI for acute STEMI [175]. Patients were stratified for door-to-balloon time
and the presence/absence of collaterals. Infarct size was measured by MRI at 5–7 days
and at 4 months. While there was no significant difference to placebo in infarct size as
measured by total late enhancement area, some interesting observations were made, which
may warrant future evaluation. The necrotic core zone, which determines the area of
non-viable myocardium, was significantly reduced, as was the amount of microvascular
obstruction (MVO). In patients presenting early (<3 hours time-to-reperfusion), compared
to placebo there was a highly significant reduction after 4 months both in necrotic core zone
(0.3% vs. 2.4%, p = 0.032) and in total infarct size (8.0% vs. 16.0%; p = 0.032), suggesting
a longer-term treatment effect in these patients. Moreover, patients with collaterals have
smaller infarcts after treatment with FX06 (7.3% vs. 15.2%; p = 0.043) [176]. Since the
loss of endothelial barrier function has pathophysiological relevance in many diseases,
FX06 has shown anecdotal beneficial effects in patients with Ebola infection [177] and
COVID-19-induced respiratory distress syndrome [178]. This latter application is now
under systematic investigation in the prospective randomized IXION trial [179].
Safety and pharmacokinetics have been investigated for the endothelial barrier sta-
bilizer CU06-1004 [NCT04795037]. This product is now in a phase 2a clinical trial in
diabetic macular edema [NCT05573100]. According to the website of the company Curacle
(www.curacle.com, accessed on 5 February 2023), a clinical development adjunct to PCI in
myocardial infarction is planned.
The G-protein biased sphingosine-1 phosphate receptor-1 (S1P1) agonist SAR247798
has been investigated for safety and PK [180]. A study with the measurement of improve-
ment of endothelial function in diabetic patients has also been completed [NCT03462017];
the results have not yet been published.
The company Vasomune (www.vasomune.com, accessed on 5 February 2023) develops
a PEGylated version of the Tie2 agonistic peptide vasculotide (AV-001) in acute respiratory
distress caused by bacterial or viral infection [NCT05123755] and in COVID-19-related
respiratory distress, which is thought to be related to endothelial barrier impairment
[NCT04737486].
None of these promising approaches have been advanced to large randomized con-
trolled trials. The results from such studies will be eagerly awaited and may provide new
avenues for treatment.

5. Conclusions and Outlook

Reperfusion therapy is firmly established as the best therapeutic modality to salvage
myocardium in patients with acute STEMI as well as in patients with cerebral ischemic
stroke. Other clinical scenarios, such as reflow in hemodynamic shutdown following
cardiac arrest, severe bleeding and hemorrhagic shock or aortic cross-clamping, are often
not recognized in this matter, although outcome is often severely compromised. It is now a
common understanding in the field that reperfusion may lead to additional tissue damage
beyond the ischemia itself. This effect has been aptly called ischemia/reperfusion injury
(IRI). It has been shown to also play a pathophysiological role in other organ systems, e.g.,
in kidney, lung and liver injury following transplantation and in respiratory distress in
bacterial and viral infections. The prevention and treatment of the deleterious effects of IRI
have therefore become a target of intense research over the last few decades [126]. While
many encouraging results have been obtained in experimental studies, the translation into
improvements in clinical outcomes has been notoriously difficult. This has even led to
questions over whether a clinical implementation will be possible at all [134].
However, we believe that this would be a premature conclusion and the need for
effective tissue-protecting strategies continues to be pressing. There is hope that a more
comprehensive characterization of candidate treatments will reveal interventions with a
higher probability of success. This approach was recently summarized in several com-
mandments [181]:
Cells 2023, 12, 1345 13 of 21

- Before being applied in a clinical setting, the effectiveness of the cardioprotective

intervention must be verified in several models, preferably including large animals
and comorbidities.
- The data should be reproducible between different study centers in multi-center trials.
- Endpoints in the latter stages of preclinical studies should mirror the clinical endpoints
that will have an impact on medical practices, such as mortality.
- Pre-clinical translational studies should start to reflect the background of current
medical therapy for STEMI patients.
The majority of pivotal large-scale clinical trials have concentrated on the protection
of cardiomyocytes from reperfusion injury. The protection of the microvasculature has
comparably received a lot less attention despite ample pathophysiological evidence of the
major role of microvascular leakage. The promising experimental results obtained with
a diverse group of interventions that prevent microvascular leak wait to be translated
into clinical applications beyond small proof of concept trials. A more detailed clinical
investigation of strategies that target the integrity of the microvascular endothelium can
certainly be expected to provide new avenues for tissue protection.
Finally, it will be a worthwhile endeavor to have a more integrative systems medicine-
based approach, which takes the complex interactions of multiple pathways involved in
IRI into account. Such multitarget approaches, which look at the myocardium and the
coronary microvasculature, have already been proposed [182,183] and may ultimately
provide solutions to this difficult problem. Taking all the learnings from 40 years of
cardio-protection studies into account will eventually provide robust approaches for organ
protection in the setting of ischemia/reperfusion injury.

Author Contributions: Conceptualization, J.A.K., P.W. and R.H.; writing—original draft preparation,
R.H. and P.W. in close cooperation with J.A.K.; writing—review and editing, R.H., P.W., B.F. and
J.A.K.; supervision: K.Z. All authors have read and agreed to the published version of the manuscript.
Funding: The results in this publication are thematically linked but not directly related to specific
activities of the project COVend, which has received funding from Horizon Europe research and
innovation programs under grant agreement No 101045956 (COVend).
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: No new data were created or analyzed in this study. Data sharing is
not applicable to this article.
Acknowledgments: The authors would like to thank Johanna Keim for the excellent visualization
of the figures and Elina Nürenberg-Goloub for her continued support and excellent professional
contribution to the project.
Conflicts of Interest: P.W. owns shares and is an employee of F4 Pharma, the developer of FX06.
All other authors declare no conflict of interest. KZ has received honoraria for participation in
advisory board meetings for Haemonetics and Vifor and received speaker fees from CSL Behring,
Masimo, Pharmacosmos, Boston Scientific, Salus, iSEP, Edwards and GE Healthcare. He is the
Principal Investigator of the EU-Horizon 2020 project ENVISION (intelligent plug-and-play digital
tool for real-time surveillance of COVID-19 patients and smart decision-making in Intensive Care
Units) and Horizon Europe 2021 project COVend (biomarker and AI-supported FX06 therapy to
prevent progression from mild and moderate to severe stages of COVID-19). J.K. and B.F. are steering
committee members of COVend and ENVISION.
Cells 2023, 12, 1345 14 of 21

References
1. Tsao, C.W.; Aday, A.W.; Almarzooq, Z.I.; Alonso, A.; Beaton, A.Z.; Bittencourt, M.S.; Boehme, A.K.; Buxton, A.E.; Carson, A.P.;
Commodore-Mensah, Y.; et al. Heart Disease and Stroke Statistics-2022 Update: A Report from the American Heart Association.
Circulation 2022, 145, E153–E639. [CrossRef]
2. Camacho, X.; Nedkoff, L.; Wright, F.L.; Nghiem, N.; Buajitti, E.; Goldacre, R.; Rosella, L.C.; Seminog, O.; Tan, E.J.; Hayes, A.; et al.
Relative Contribution of Trends in Myocardial Infarction Event Rates and Case Fatality to Declines in Mortality: An International
Comparative Study of 1·95 Million Events in 80·4 Million People in Four Countries. Lancet Public Health 2022, 7, e229–e239.
[CrossRef]
3. Jenča, D.; Melenovský, V.; Stehlik, J.; Staněk, V.; Kettner, J.; Kautzner, J.; Adámková, V.; Wohlfahrt, P. Heart Failure after Myocardial
Infarction: Incidence and Predictors. ESC Heart Fail. 2021, 8, 222–237. [CrossRef]
4. Frantz, S.; Hundertmark, M.J.; Schulz-Menger, J.; Bengel, F.M.; Bauersachs, J. Left Ventricular Remodelling Post-Myocardial
Infarction: Pathophysiology, Imaging, and Novel Therapies. Eur. Heart J. 2022, 43, 2549–2561. [CrossRef]
5. Frank, A.; Bonney, M.; Bonney, S.; Weitzel, L.; Koeppen, M.; Eckle, T. Myocardial Ischemia Reperfusion Injury: From Basic Science
to Clinical Bedside. Sem. Cardiothorac. Vasc. Anesth. 2012, 16, 123–132. [CrossRef]
6. Beyersdorf, F.; Trummer, G.; Benk, C.; Pooth, J.S. Application of Cardiac Surgery Techniques to Improve the Results of Cardiopul-
monary Resuscitation after Cardiac Arrest: Controlled Automated Reperfusion of the Whole Body. JTCVS Open 2021, 8, 47–52.
[CrossRef]
7. Fu, Z.Y.; Wu, Z.J.; Zheng, J.H.; Qin, T.; Yang, Y.G.; Chen, M.H. The Incidence of Acute Kidney Injury Following Cardiac Arrest
and Cardiopulmonary Resuscitation in a Rat Model. Ren. Fail. 2019, 41, 278–283. [CrossRef]
8. Sandroni, C.; Cronberg, T.; Sekhon, M. Brain Injury after Cardiac Arrest: Pathophysiology, Treatment, and Prognosis. Intensive
Care Med. 2021, 47, 1393–1414. [CrossRef]
9. Cannon, J.W. Hemorrhagic Shock. N. Engl. J. Med. 2018, 378, 370–379. [CrossRef]
10. Yeung, K.K.; Groeneveld, M.; Lu, J.J.N.; van Diemen, P.; Jongkind, V.; Wisselink, W. Organ Protection during Aortic Cross-
Clamping. Best Pract. Res. Clin. Anaesthesiol. 2016, 30, 305–315. [CrossRef]
11. Nielsen, E.W.; Miller, Y.; Brekke, O.L.; Grond, J.; Duong, A.H.; Fure, H.; Ludviksen, J.K.; Pettersen, K.; Reubsaet, L.; Solberg,
R.; et al. A Novel Porcine Model of Ischemia-Reperfusion Injury After Cross-Clamping the Thoracic Aorta Revealed Substantial
Cardiopulmonary, Thromboinflammatory and Biochemical Changes Without Effect of C1-Inhibitor Treatment. Front. Immunol.
2022, 13, 852119. [CrossRef]
12. Soares, R.O.S.; Losada, D.M.; Jordani, M.C.; Évora, P.; Castro-E-Silva, O. Ischemia/Reperfusion Injury Revisited: An Overview of
the Latest Pharmacological Strategies. Int. J. Mol. Sci. 2019, 20, 5034. [CrossRef]
13. Heusch, G. Myocardial Ischaemia–Reperfusion Injury and Cardioprotection in Perspective. Nat. Rev. Cardiol. 2020, 17, 773–789.
[CrossRef]
14. He, J.; Liu, D.; Zhao, L.; Zhou, D.; Rong, J.; Zhang, L.; Xia, Z. Myocardial Ischemia/Reperfusion Injury: Mechanisms of Injury and
Implications for Management (Review). Exp. Ther. Med. 2022, 23, 430. [CrossRef]
15. Wu, M.Y.; Yiang, G.T.; Liao, W.T.; Tsai, A.P.Y.; Cheng, Y.L.; Cheng, P.W.; Li, C.Y.; Li, C.J. Current Mechanistic Concepts in Ischemia
and Reperfusion Injury. Cell Physiol. Biochem. 2018, 46, 1650–1667. [CrossRef]
16. Jennings, R.B. Historical Perspective on the Pathology of Myocardial Ischemia/Reperfusion Injury. Circ. Res. 2013, 113, 428–438.
[CrossRef]
17. Jennings, R.B.; Sommers, H.M.; Smyth, G.A.; Flack, H.A.; Linn, H. Myocardial Necrosis Induced by Temporary Occlusion of a
Coronary Artery in Dogs. Arch. Pathol. 1960, 70, 68–78.
18. Enzmann, G.; Kargaran, S.; Engelhardt, B. Ischemia–Reperfusion Injury in Stroke: Impact of the Brain Barriers and Brain Immune
Privilege on Neutrophil Function. Ther. Adv. Neurol Disord. 2018, 11, 1–15. [CrossRef]
19. Lin, L.; Wang, X.; Yu, Z. Ischemia-Reperfusion Injury in the Brain: Mechanisms and Potential Therapeutic Strategies. Biochem.
Pharmacol. 2016, 5, 4. [CrossRef]
20. Nieuwenhuijs-Moeke, G.J.; Pischke, S.E.; Berger, S.P.; Sanders, J.S.F.; Pol, R.A.; Struys, M.M.R.F.; Ploeg, R.J.; Leuvenink, H.G.D.
Ischemia and Reperfusion Injury in Kidney Transplantation: Relevant Mechanisms in Injury and Repair. J. Clin. Med. 2020, 9, 253.
[CrossRef]
21. Zhai, Y.; Petrowsky, H.; Hong, J.C.; Busuttil, R.W.; Kupiec-Weglinski, J.W. Ischaemia-Reperfusion Injury in Liver Transplantation-
from Bench to Bedside. Nat. Rev. Gastroenterol. Hepatol. 2013, 10, 79–89. [CrossRef]
22. Chen-Yoshikawa, T.F. Ischemia–Reperfusion Injury in Lung Transplantation. Cells 2021, 10, 1333. [CrossRef]
23. Heusch, G.; Gersh, B.J. The Pathophysiology of Acute Myocardial Infarction and Strategies of Protection beyond Reperfusion: A
Continual Challenge. Eur. Heart J. 2017, 38, 774–784. [CrossRef]
24. Leineweber, K.; Böse, D.; Vogelsang, M.; Haude, M.; Erbel, R.; Heusch, G. Intense Vasoconstriction in Response to Aspirate from
Stented Saphenous Vein Aortocoronary Bypass Grafts. J. Am. Coll. Cardiol. 2006, 47, 981–986. [CrossRef]
25. Heusch, G.; Kleinbongard, P.; Böse, D.; Levkau, B.; Haude, M.; Schulz, R.; Erbel, R. Coronary Microembolization: From Bedside to
Bench and Back to Bedside. Circulation 2009, 120, 1822–1836. [CrossRef]
26. Niccoli, G.; Burzotta, F.; Galiuto, L.; Crea, F. Myocardial No-Reflow in Humans. J. Am. Coll. Cardiol. 2010, 55, 281–292. [CrossRef]
Cells 2023, 12, 1345 15 of 21

27. Ndrepepa, G.; Tiroch, K.; Fusaro, M.; Keta, D.; Seyfarth, M.; Byrne, R.A.; Pache, J.; Alger, P.; Mehilli, J.; Schömig, A.; et al. 5-Year
Prognostic Value of No-Reflow Phenomenon After Percutaneous Coronary Intervention in Patients With Acute Myocardial
Infarction. J. Am. Coll. Cardiol. 2010, 55, 2383–2389. [CrossRef]
28. Hamirani, Y.S.; Wong, A.; Kramer, C.M.; Salerno, M. Effect of Microvascular Obstruction and Intramyocardial Hemorrhage by
CMR on LV Remodeling and Outcomes after Myocardial Infarction: A Systematic Review and Meta-Analysis. JACC Cardiovasc.
Imaging 2014, 7, 940–952. [CrossRef]
29. Yang, Q.; He, G.-W.; Underwood, M.J.; Yu, C.-M. Review Article Cellular and Molecular Mechanisms of Endothelial Is-
chemia/Reperfusion Injury: Perspectives and Implications for Postischemic Myocardial Protection. Am. J. Transl. Res. 2016, 8,
765–777.
30. Francischetti, I.; Moreno, J.B.J.; Scholz, M.; Yoshida, W.B. Leukocytes and the Inflammatory Response in Ischemia-Reperfusion
Injury. Rev. Bras. Circ. Cardiovasc. 2010, 25, 575–584. [CrossRef]
31. Sezer, M.; Van Royen, N.; Umman, B.; Bugra, Z.; Bulluck, H.; Hausenloy, D.J.; Umman, S. Coronary Microvascular Injury in
Reperfused Acute Myocardial Infarction: A View from an Integrative Perspective. J. Am. Heart Assoc. 2018, 7, e009949. [CrossRef]
32. Carrick, D.; Haig, C.; Ahmed, N.; Rauhalammi, S.; Clerfond, G.; Carberry, J.; Mordi, I.; McEntegart, M.; Petrie, M.C.; Eteiba,
H.; et al. Temporal Evolution of Myocardial Hemorrhage and Edema in Patients after Acute St-Segment Elevation Myocardial
Infarction: Pathophysiological Insights and Clinical Implications. J. Am. Heart Assoc. 2016, 5, e002834. [CrossRef]
33. Bonfig, N.L.; Soukup, C.R.; Shah, A.A.; Olet, S.; Davidson, S.J.; Schmidt, C.W.; Peterson, R.; Henry, T.D.; Traverse, J.H. Increasing
Myocardial Edema Is Associated with Greater Microvascular Obstruction in ST-Segment Elevation Myocardial Infarction. Am. J.
Physiol. Heart Circ. Physiol. 2022, 323, H818–H824. [CrossRef]
34. Gao, X.-M.; Wu, Q.-Z.; Kiriazis, H.; Su, Y.; Han, L.-P.; Todd Pearson, J.; Taylor, A.J.; Du, X.-J. Microvascular Leakage in Acute
Myocardial Infarction: Characterization by Histology, Biochemistry, and Magnetic Resonance Imaging. Am. J. Physiol. Heart Circ.
Physiol. 2017, 312, 1068–1075. [CrossRef]
35. Huang, L.H.; Lavine, K.J.; Randolph, G.J. Cardiac Lymphatic Vessels, Transport, and Healing of the Infarcted Heart. JACC Basic
Transl. Sci. 2017, 2, 477–483. [CrossRef]
36. Sumii, T.; Lo, E.H. Involvement of Matrix Metalloproteinase in Thrombolysis-Associated Hemorrhagic Transformation After
Embolic Focal Ischemia in Rats. Stroke 2002, 33, 831–836. [CrossRef]
37. Warach, S.; Latour, L.L. Evidence of Reperfusion Injury, Exacerbated by Thrombolytic Therapy, in Human Focal Brain Ischemia
Using a Novel Imaging Marker of Early Blood-Brain Barrier Disruption. Stroke 2004, 35, 2659–2661. [CrossRef]
38. Salvadori, M.; Rosso, G.; Bertoni, E. Update on Ischemia-Reperfusion Injury in Kidney Transplantation: Pathogenesis and
Treatment. World J. Transplant. 2015, 5, 52. [CrossRef]
39. Hidalgo, M.A.; Shah, K.A.; Fuller, B.J.; Green, C.J. Cold ischemia-induced damage to vascular endothelium results in permeability
alterations in transplanted lungs. J. Thorac. Cardiovasc. Surg. 1996, 112, 1027–1035. [CrossRef]
40. Pulitano, C.; Joseph, D.; Sandroussi, C.; Verran, D.; Ho, P.; Debiasio, A.; Luongo, A.; McCaughan, G.W.; Shackel, N.A.;
Crawford, M. Postreperfusion Microcirculatory Derangements after Liver Transplantation: Relationship to Hemodynamics,
Serum Mediators, and Outcome. Liver Transplant. 2017, 23, 527–536. [CrossRef]
41. Neumar, R.W.; Nolan, J.P.; Adrie, C.; Aibiki, M.; Berg, R.A.; Böttiger, B.W.; Callaway, C.; Clark, R.S.B.; Geocadin, R.G.; Jauch, E.C.;
et al. Vanden. Post-Cardiac Arrest Syndrome: Epidemiology, Pathophysiology, Treatment, and Prognostication a Consensus
Statement from the International Liaison Committee on Resuscitation. Circulation 2008, 18, 2452–2483. [CrossRef]
42. Kang, Y. Management of Post-Cardiac Arrest Syndrome. Acute Crit. Care 2019, 34, 173–178. [CrossRef]
43. The Hypothermia after Cardia Arrest Study Group. Mild Therapeutic Hypothermia to Improve the Neurological Outcome after
Cardiac Arrest. N. Eng. J. Med. 2002, 346, 549–556. [CrossRef]
44. Meybohm, P.; Gruenewald, M.; Albrecht, M.; Zacharowski, K.D.; Lucius, R.; Zitta, K.; Koch, A.; Tran, N.; Scholz, J.; Bein, B. Hy-
pothermia and Postconditioning after Cardiopulmonary Resuscitation Reduce Cardiac Dysfunction by Modulating Inflammation,
Apoptosis and Remodeling. PLoS ONE 2009, 4, e7588. [CrossRef]
45. Chia, P.Y.; Teo, A.; Yeo, T.W. Overview of the Assessment of Endothelial Function in Humans. Front. Med. 2020, 7, 542567.
[CrossRef]
46. Tiwari, A.; Elgrably, B.; Saar, G.; Vandoorne, K. Multi-Scale Imaging of Vascular Pathologies in Cardiovascular Disease. Front.
Med. 2022, 9, 754369. [CrossRef]
47. Chistiakov, D.A.; Orekhov, A.N.; Bobryshev, Y.V. Endothelial Barrier and Its Abnormalities in Cardiovascular Disease. Front.
Physiol. 2015, 6, 365. [CrossRef]
48. Wettschureck, N.; Strilic, B.; Offermanns, S. Passing the Vascular Barrier: Endothelial Signaling Processes Controlling Extravasa-
tion. Physiol. Rev. 2019, 99, 1467–1525. [CrossRef]
49. Dejana, E.; Vestweber, D. The Role of VE-Cadherin in Vascular Morphogenesis and Permeability Control. Prog. Mol. Biol. Transl.
Sci. 2013, 116, 119–144. [CrossRef]
50. Yang, Y.J.; Zhao, J.L.; You, S.J.; Wu, Y.J.; Jing, Z.C.; Gao, R.L.; Chen, Z.J. Post-Infarction Treatment with Simvastatin Reduces
Myocardial No-Reflow by Opening of the KATP Channel. Eur. J. Heart Fail. 2007, 9, 30–36. [CrossRef]
51. van Buul, J.D.; Timmerman, I. Small Rho GTPase-Mediated Actin Dynamics at Endothelial Adherens Junctions. Small GTPases
2016, 7, 21–31. [CrossRef]
Cells 2023, 12, 1345 16 of 21

52. Timmerman, I.; Heemskerk, N.; Kroon, J.; Schaefer, A.; van Rijssel, J.; Hoogenboezem, M.; van Unen, J.; Goedhart, J.; Gadella,
T.W.J.; Yin, T.; et al. Correction to “A Local VE-Cadherin and Trio-Based Signaling Complex Stabilizes Endothelial Junctions
through Rac1”. J. Cell Sci. 2015, 128, 3514. [CrossRef]
53. Wallez, Y.; Cand, F.; Cruzalegui, F.; Wernstedt, C.; Souchenalytskyi, S.; Vilgrain, I.; Huber, P. Src Kinase Phosphorylates Vascular
Endothelial-Cadherin in Response to Vascular Endothelial Growth Factor: Identification of Tyrosine 685 as the Unique Target Site.
Oncogene 2007, 26, 1067–1077. [CrossRef]
54. Nawroth, R.; Poell, G.; Ranft, A.; Kloep, S.; Samulowitz, U.; Fachinger, G.; Golding, M.; Shima, D.T.; Deutsch, U.; Vestweber, D.
VE-PTP and VE-Cadherin Ectodomains Interact to Facilitate Regulation of Phosphorylation and Cell Contacts. EMBO J. 2002, 21,
4885–4895. [CrossRef]
55. Hilbert, T.; Klaschik, S. The Angiopoietin/TIE Receptor System: Focusing Its Role for Ischemia-Reperfusion Injury. Cytokine
Growth Factor Rev. 2015, 26, 281–291. [CrossRef]
56. Zhang, Y.; Kontos, C.D.; Annex, B.H.; Popel, A.S. Angiopoietin-Tie Signaling Pathway in Endothelial Cells: A Computational
Model. iScience 2019, 20, 497–511. [CrossRef]
57. Lee, S.W.; Won, J.Y.; Lee, H.Y.; Lee, H.J.; Youn, S.W.; Lee, J.Y.; Cho, C.H.; Cho, H.J.; Oh, S.; Chae, I.H.; et al. Angiopoietin-1 Protects
Heart against Ischemia/Reperfusion Injury through VE-Cadherin Dephosphorylation and Myocardiac Integrin-B1/ERK/Caspase-
9 Phosphorylation Cascade. Mol. Med. 2011, 17, 1095–1106. [CrossRef]
58. Patel, J.v.; Lim, H.S.; Varughese, G.I.; Hughes, E.A.; Lip, G.Y.H. Angiopoietin-2 Levels as a Biomarker of Cardiovascular Risk in
Patients with Hypertension. Ann. Med. 2008, 40, 215–222. [CrossRef]
59. Lee, S.J.; Lee, C.K.; Kang, S.; Park, I.; Kim, Y.H.; Kim, S.K.; Hong, S.P.; Bae, H.; He, Y.; Kubota, Y.; et al. Angiopoietin-2 Exacerbates
Cardiac Hypoxia and Inflammation after Myocardial Infarction. J. Clin. Investig. 2018, 128, 5018–5033. [CrossRef]
60. Shen, J.; Frye, M.; Lee, B.L.; Reinardy, J.L.; McClung, J.M.; Ding, K.; Kojima, M.; Xia, H.; Seidel, C.; Lima E Silva, R.; et al. Targeting
VE-PTP Activates TIE2 and Stabilizes the Ocular Vasculature. J. Clin. Investig. 2014, 124, 4564–4576. [CrossRef]
61. Souma, T.; Thomson, B.R.; Heinen, S.; Carota, I.A.; Yamaguchi, S.; Onay, T.; Liu, P.; Ghosh, A.K.; Li, C.; Eremina, V.; et al.
Context-Dependent Functions of Angiopoietin 2 Are Determined by the Endothelial Phosphatase VEPTP. Proc. Natl. Acad. Sci.
USA 2018, 115, 1298–1303. [CrossRef]
62. Raza, Z.; Saleem, U.; Naureen, Z. Sphingosine 1-Phosphate Signaling in Ischemia and Reperfusion Injury. Prostaglandins Other
Lipid Mediat. 2020, 149, 106436. [CrossRef]
63. Wilkerson, B.A.; Argraves, K.M. The Role of Sphingosine-1-Phosphate in Endothelial Barrier Function. Biochim. Biophys. Acta
2014, 1841, 1403–1412. [CrossRef]
64. Morel, S.; Christoffersen, C.; Axelsen, L.N.; Montecucco, F.; Rochemont, V.; Frias, M.A.; Mach, F.; James, R.W.; Naus, C.C.;
Chanson, M.; et al. Sphingosine-1-Phosphate Reduces Ischaemia-Reperfusion Injury by Phosphorylating the Gap Junction Protein
Connexin43. Cardiovasc. Res. 2016, 109, 385–396. [CrossRef]
65. Nitzsche, A.; Poittevin, M.; Benarab, A.; Bonnin, P.; Faraco, G.; Uchida, H.; Favre, J.; Garcia-Bonilla, L.; Garcia, M.C.L.; Léger, P.L.;
et al. Endothelial S1P1 Signaling Counteracts Infarct Expansion in Ischemic Stroke. Circ. Res. 2021, 128, 363–382. [CrossRef]
66. Kong, Q.; Dai, L.; Wang, Y.; Zhang, X.; Li, C.; Jiang, S.; Li, Y.; Ding, Z.; Liu, L. HSPA12B Attenuated Acute Myocardial
Ischemia/Reperfusion Injury via Maintaining Endothelial Integrity in a PI3K/Akt/MTOR-Dependent Mechanism. Sci. Rep. 2016,
6, 33636. [CrossRef]
67. Andrés-Villarreal, M.; Barba, I.; Poncelas, M.; Inserte, J.; Rodriguez-Palomares, J.; Pineda, V.; Garcia-Dorado, D. Measuring
Water Distribution in the Heart: Preventing Edema Reduces Ischemia-Reperfusion Injury. J. Am. Heart Assoc. 2016, 5, e003843.
[CrossRef]
68. Ng, F.C.; Churilov, L.; Yassi, N.; Kleinig, T.J.; Thijs, V.; Wu, T.Y.; Shah, D.G.; Dewey, H.M.; Sharma, G.; Desmond, P.M.; et al.
Microvascular Dysfunction in Blood-Brain Barrier Disruption and Hypoperfusion Within the Infarct Posttreatment Are Associated
with Cerebral Edema. Stroke 2022, 53, 1597–1605. [CrossRef]
69. Sutton, T.A. Alteration of Microvascular Permeability in Acute Kidney Injury. Microvasc. Res. 2009, 77, 4–7. [CrossRef]
70. Heusch Gerd. Treatment of Myocardial Ischemia/Reperfusion Injury by Ischemic and Pharmacological Postconditioning. Compr.
Physiol. 2015, 5, 1123–1145.
71. Hausenloy, D.J.; Yellon, D.M. New Directions for Protecting the Heart against Ischaemia-Reperfusion Injury: Targeting the
Reperfusion Injury Salvage Kinase (RISK)-Pathway. Cardiovasc. Res. 2004, 61, 448–460. [CrossRef]
72. Hadebe, N.; Cour, M.; Lecour, S. The SAFE Pathway for Cardioprotection: Is This a Promising Target? Basic Res. Cardiol. 2018,
113, 9. [CrossRef]
73. Zhou, M.; Yu, Y.; Luo, X.; Wang, J.; Lan, X.; Liu, P.; Feng, Y.; Jian, W. Myocardial Ischemia-Reperfusion Injury: Therapeutics from a
Mitochondria-Centric Perspective. Cardiology 2021, 146, 781–792. [CrossRef]
74. Kosieradzki, M.; Pratschke, J.; Kupiec-W˛egliński, J.; Rowiński, W. Ischemia/Reperfusion Injury, Its Mechanisms, and Prevention.
J. Transplant. 2012, 2012, 610370. [CrossRef]
75. Bai, J.; Lyden, P.D. Revisiting Cerebral Postischemic Reperfusion Injury: New Insights in Understanding Reperfusion Failure,
Hemorrhage, and Edema. Int. J. Stroke 2015, 10, 143–152. [CrossRef]
76. Pawitan, J.A. Potential Agents against Plasma Leakage. ISRN Pharmacol. 2011, 2011, 975048. [CrossRef]
77. Ahrens, I.; Peter, K. FX-06, a Fibrin-Derived Bβ15-42 Peptide for the Potential Treatment of Reperfusion Injury Following
Myocardial Infarction. Curr. Opin. Investig. Drugs 2009, 10, 997–1003.
Cells 2023, 12, 1345 17 of 21

78. Henning, R.; Zacharowski, K.; Petzelbauer, P. FX06 (Fibrin-Derived Peptide Bbeta15-42)-A Potential Candidate for Myocardial
Reperfusion Therapy. Drugs Future 2006, 31, 811. [CrossRef]
79. Jennewein, C.; Tran, N.; Paulus, P.; Ellinghaus, P.; Eble, J.A.; Zacharowski, K. Novel Aspects of Fibrin(Ogen) Fragments during
Inflammation. Mol. Med. 2011, 17, 568–573. [CrossRef]
80. Sörensen, I.; Rong, S.; Susnik, N.; Gueler, F.; Shushakova, N.; Albrecht, M.; Dittrich, A.-M.; von Vietinghoff, S.; Becker, J.U.; Melk,
A.; et al. Bβ15–42 Attenuates the Effect of Ischemia-Reperfusion Injury in Renal Transplantation. J. Am. Soc. Nephrol. 2011, 22,
1887–1896. [CrossRef]
81. Tian, Z.; Dong, B.; Blackwell, J.W.; Stewart, P.W.; Egan, T.M. Effect of a Vascular Endothelial Cadherin Antagonist in a Rat Lung
Transplant Model. Ann. Thorac. Surg. 2013, 95, 1028–1033. [CrossRef]
82. Liu, A.; Fang, H.; Yang, Y.; Sun, J.; Fan, H.; Liu, S.; Dirsch, O.; Dahmen, U. The Fibrin-Derived Peptide Bβ15-42 Attenuates Liver
Damage in a Rat Model of Liver Ischemia/Reperfusion Injury. Shock 2013, 39, 397–403. [CrossRef] [PubMed]
83. Wiedemann, D.; Schneeberger, S.; Friedl, P.; Zacharowski, K.; Wick, N.; Boesch, F.; Margreiter, R.; Laufer, G.; Petzelbauer, P.;
Semsroth, S. The Fibrin-Derived Peptide Bβ15-42 Significantly Attenuates Ischemia-Reperfusion Injury in a Cardiac Transplant
Model. Transplantation 2010, 89, 824–829. [CrossRef] [PubMed]
84. Petzelbauer, P.; Zacharowski, P.A.; Miyazaki, Y.; Friedl, P.; Wickenhauser, G.; Castellino, F.J.; Gröger, M.; Wolff, K.; Zacharowski, K.
The Fibrin-Derived Peptide Bβ15–42 Protects the Myocardium against Ischemia-Reperfusion Injury. Nat. Med. 2005, 11, 298–304.
[CrossRef]
85. Zacharowski, K.; Zacharowski, P.A.; Friedl, P.; Mastan, P.; Koch, A.; Boehm, O.; Rother, R.P.; Reingruber, S.; Henning, R.;
Emeis, J.J.; et al. The Effects of the Fibrin-Derived Peptide Bβ15-42 in Acute and Chronic Rodent Models of Myocardial
Ischemia-Reperfusion. Shock 2007, 27, 631–637. [CrossRef]
86. Roesner, J.P.; Petzelbauer, P.; Koch, A.; Mersmann, J.; Zacharowski, P.A.; Boehm, O.; Reingruber, S.; Pasteiner, W.; Mascher, D.;
Wolzt, M.; et al. The Fibrin-Derived Peptide Bβ15–42 Is Cardioprotective in a Pig Model of Myocardial Ischemia-Reperfusion
Injury. Crit. Care Med. 2007, 35, 1730–1735. [CrossRef]
87. Roesner, J.P.; Petzelbauer, P.; Koch, A.; Tran, N.; Iber, T.; Mutz, C.; Vollmar, B.; Nöldge-Schomburg, G.E.F.; Zacharowski, K. A
Double Blind, Single Centre, Sub-Chronic Reperfusion Trial Evaluating FX06 Following Haemorrhagic Shock in Pigs. Resuscitation
2009, 80, P264–P271. [CrossRef]
88. Roesner, J.P.; Petzelbauer, P.; Koch, A.; Tran, N.; Iber, T.; Vagts, D.A.; Scheeren, T.W.; Vollmar, B.; Nöldge-Schomburg, G.E.;
Zacharowski, K. Bβ15-42 (FX06) Reduces Pulmonary, Myocardial, Liver, and Small Intestine Damage in a Pig Model of Hemor-
rhagic Shock and Reperfusion. Crit. Care Med. 2009, 37, 598–605. [CrossRef]
89. Bergt, S.; Gruenewald, M.; Beltschany, C.; Grub, A.; Neumann, T.; Albrecht, M.; Vollmar, B.; Zacharowski, K.; Roesner,
J.P.; Meybohm, P. The Fibrin-Derived Peptide Bβ15–42 (FX06) Ameliorates Vascular Leakage and Improves Survival and
Neurocognitive Recovery: Implications From Two Animal Models of Cardiopulmonary Resuscitation. Crit. Care Med. 2016, 44,
e988–e995. [CrossRef]
90. Urbschat, A.; Rupprecht, K.; Zacharowski, K.; Obermüller, N.; Scheller, B.; Holfeld, J.; Tepeköylü, C.; Hofmann, R.; Paulus, P.
Combined Peri-Ischemic Administration of Bβ15–42 in Treating Ischemia Reperfusion Injury of the Mouse Kidney. Microvasc.
Res. 2015, 101, 48–54. [CrossRef]
91. Krishnamoorthy, A.; Ajay, A.K.; Hoffmann, D.; Kim, T.M.; Ramirez, V.; Campanholle, G.; Bobadilla, N.A.; Waikar, S.S.; Vaidya,
V.S. Fibrinogen β-Derived Bβ15-42 Peptide Protects against Kidney Ischemia/Reperfusion Injury. Blood 2011, 118, 1934–1942.
[CrossRef]
92. Urbschat, A.; Zacharowski, K.; Obermüller, N.; Rupprecht, K.; Penzkofer, D.; Jennewein, C.; Tran, N.; Scheller, B.; Dimmeler, S.;
Paulus, P. The Small Fibrinopeptide Bβ15-42 as Renoprotective Agent Preserving the Endothelial and Vascular Integrity in Early
Ischemia Reperfusion Injury in the Mouse Kidney. PLoS ONE 2014, 9, e84432. [CrossRef]
93. Jennewein, C.; Mehring, M.; Tran, N.; Paulus, P.; Ockelmann, P.A.; Habeck, K.; Latsch, K.; Scheller, B.; Zacharowski, K.; Mutlak, H.
The Fibrinopeptide Lβ15-42 Reduces Inflammation in Mice Subjected to Polymicrobial Sepsis. Shock 2012, 38, 275–280. [CrossRef]
94. Tang, H.; Abouleila, Y.; Mashaghi, A. Lassa Hemorrhagic Shock Syndrome-on-a-Chip. Biotechnol. Bioeng. 2021, 118, 1405–1410.
[CrossRef]
95. Westover, J.B.; Hickerson, B.T.; van Wettere, A.J.; Hurst, B.L.; Kurz, J.P.; Dagley, A.; Wülfroth, P.; Komeno, T.; Furuta, Y.; Steiner,
T.; et al. Vascular Leak and Hypercytokinemia Associated with Severe Fever with Thrombocytopenia Syndrome Virus Infection
in Mice. Pathogens 2019, 8, 158. [CrossRef]
96. Gröger, M.; Pasteiner, W.; Ignatyev, G.; Matt, U.; Knapp, S.; Atrasheuskaya, A.; Bukin, E.; Freidl, P.; Zinkl, D.; Hofer-Warbinek,
R.; et al. Peptide Bβ15-42 Preserves Endothelial Barrier Function in Shock. PLoS ONE 2009, 4, e5391. [CrossRef]
97. Yakovlev, S.; Cao, C.; Galisteo, R.; Zhang, L.; Strickland, D.K.; Medved, L. Fibrin-VLDL Receptor-Dependent Pathway Promotes
Leukocyte Transmigration by Inhibiting Src Kinase Fyn and Is a Target for Fibrin B15-42 Peptide. Thromb. Haemost. 2019, 119,
1816–1826. [CrossRef]
98. Ludwig, N.; Rossaint, J. Fibrin Degradation Product B15-42-New Insights in an Old Pathway. Thromb. Haemost. 2019, 119, 1719.
[CrossRef]
99. Zhang, H.; Kim, H.; Park, B.W.; Noh, M.; Kim, Y.; Park, J.; Park, J.H.; Kim, J.J.; Sim, W.S.; Ban, K.; et al. CU06-1004 Enhances
Vascular Integrity and Improves Cardiac Remodeling by Suppressing Edema and Inflammation in Myocardial Ischemia–
Reperfusion Injury. Exp. Mol. Med. 2022, 54, 23–34. [CrossRef]
Cells 2023, 12, 1345 18 of 21

100. Zhang, H.; Park, J.H.; Maharjan, S.; Park, J.A.; Choi, K.-S.; Park, H.; Jeong, Y.; Ahn, J.H.; Kim, I.H.; Lee, J.-C.; et al. Sac-1004, a
Vascular Leakage Blocker, Reduces Cerebral Ischemia—Reperfusion Injury by Suppressing Blood–Brain Barrier Disruption and
Inflammation. J. Neuroinflamm. 2017, 14, 122. [CrossRef]
101. Kim, D.Y.; Zhang, H.; Park, S.; Kim, Y.; Bae, C.R.; Kim, Y.M.; Kwon, Y.G. CU06-1004 (Endothelial Dysfunction Blocker) Ameliorates
Astrocyte End-Feet Swelling by Stabilizing Endothelial Cell Junctions in Cerebral Ischemia/Reperfusion Injury. J Mol. Med. 2020,
98, 875–886. [CrossRef] [PubMed]
102. Kim, Y.S.; Zhang, H.; Lee, S.; Park, S.; Noh, M.; Kim, Y.M.; Kwon, Y.G. CU06-1004 Alleviates Experimental Colitis by Modulating
Colonic Vessel Dysfunction. Front. Pharmacol. 2020, 11, 571266. [CrossRef] [PubMed]
103. Maharjan, S.; Lee, S.; Agrawal, V.; Choi, H.J.; Maeng, Y.S.; Kim, K.; Kim, N.J.; Suh, Y.G.; Kwon, Y.G. Sac-0601 Prevents Retinal
Vascular Leakage in a Mouse Model of Diabetic Retinopathy. Eur. J. Pharmacol. 2011, 657, 35–40. [CrossRef]
104. Noh, M.; Kim, Y.; Zhang, H.; Kim, H.; Bae, C.R.; Lee, S.; Kwon, Y.G. Oral Administration of CU06-1004 Attenuates Vascular
Permeability and Stabilizes Neovascularization in Retinal Vascular Diseases. Eur. J. Pharmacol. 2023, 939, 175427. [CrossRef]
[PubMed]
105. Park, S.; Oh, J.H.; Park, D.J.; Zhang, H.; Noh, M.; Kim, Y.; Kim, Y.S.; Kim, H.; Kim, Y.M.; Ha, S.J.; et al. CU06-1004-Induced Vascular
Normalization Improves Immunotherapy by Modulating Tumor Microenvironment via Cytotoxic T Cells. Front. Immunol. 2021,
11, 620111. [CrossRef]
106. Maharjan, S.; Kim, K.; Agrawal, V.; Choi, H.J.; Kim, N.J.; Kim, Y.M.; Suh, Y.G.; Kwon, Y.G. Sac-1004, a Novel Vascular Leakage
Blocker, Enhances Endothelial Barrier through the CAMP/Rac/Cortactin Pathway. Biochem. Biophys. Res. Commun. 2013, 435,
420–427. [CrossRef] [PubMed]
107. Galaup, A.; Gomez, E.; Souktani, R.; Durand, M.; Cazes, A.; Monnot, C.; Teillon, J.; Le Jan, S.; Bouleti, C.; Briois, G.; et al.
Protection Against Myocardial Infarction and No-Reflow Through Preservation of Vascular Integrity by Angiopoietin-Like 4.
Circulation 2012, 125, 140–149. [CrossRef]
108. Wang, Z.Y.; Lin, J.Y.; Feng, Y.R.; Liu, D.S.; Zhao, X.Z.; Li, T.; Li, S.Y.; Sun, J.C.; Li, S.F.; Jia, W.Y.; et al. Recombinant Angiopoietin-like
Protein 4 Attenuates Intestinal Barrier Structure and Function Injury after Ischemia/Reperfusion. World J. Gastroenterol. 2021, 27,
5404–5423. [CrossRef] [PubMed]
109. Qi, K.; Li, X.; Geng, Y.; Cui, H.; Jin, C.; Wang, P.; Li, Y.; Yang, Y. Tongxinluo Attenuates Reperfusion Injury in Diabetic Hearts by
Angiopoietin-like 4-Mediated Protection of Endothelial Barrier Integrity via PPAR-α Pathway. PLoS ONE 2018, 13, e0198403.
[CrossRef]
110. Rübig, E.; Stypmann, J.; van Slyke, P.; Dumont, D.J.; Spieker, T.; Buscher, K.; Reuter, S.; Goerge, T.; Pavenstädt, H.; Kümpers, P.
The Synthetic Tie2 Agonist Peptide Vasculotide Protects Renal Vascular Barrier Function in Experimental Acute Kidney Injury.
Sci. Rep. 2016, 6, 22111. [CrossRef]
111. Jung, Y.J.; Kim, D.H.; Lee, A.S.; Lee, S.; Kang, K.P.; Lee, S.Y.; Jang, K.Y.; Sung, M.J.; Park, S.K.; Kim, W. Peritubular Capillary
Preservation with COMP-Angiopoietin-1 Decreases Ischemia-Reperfusion-Induced Acute Kidney Injury. Am. J. Physiol. Renal.
Physiol 2009, 297, F952-60. [CrossRef] [PubMed]
112. Syrjälä, S.O.; Nykänen, A.I.; Tuuminen, R.; Raissadati, A.; Keränen, M.A.I.; Arnaudova, R.; Krebs, R.; Koh, G.Y.; Alitalo, K.;
Lemström, K.B. Donor Heart Treatment with COMP-Ang1 Limits Ischemia-Reperfusion Injury and Rejection of Cardiac Allografts.
Am. J. Transplant. 2015, 15, 2075–2084. [CrossRef] [PubMed]
113. Wang, Z.; Higashikawa, K.; Yasui, H.; Kuge, Y.; Ohno, Y.; Kihara, A.; Midori, Y.A.; Houkin, K.; Kawabori, M. FTY720 Protects
Against Ischemia–Reperfusion Injury by Preventing the Redistribution of Tight Junction Proteins and Decreases Inflammation in
the Subacute Phase in an Experimental Stroke Model. Transl. Stroke Res. 2020, 11, 1103–1116. [CrossRef] [PubMed]
114. Poirier, B.; Briand, V.; Kadereit, D.; Schäfer, M.; Wohlfart, P.; Philippo, M.-C.; Caillaud, D.; Gouraud, L.; Grailhe, P.; Bidouard,
J.-P.; et al. A G Protein–Biased S1P 1 Agonist, SAR247799, Protects Endothelial Cells without Affecting Lymphocyte Numbers. Sci.
Signal. 2020, 13, eaax8050. [CrossRef]
115. Li, X.; Gui, Z.; Liu, H.; Qian, S.; Jia, Y.; Luo, X. Remifentanil Pretreatment Ameliorates H/R-Induced Cardiac Microvascular
Endothelial Cell Dysfunction by Regulating the PI3K/Akt/HIF-1α Signaling Pathway. Bioengineered 2021, 12, 7872–7881.
[CrossRef]
116. Gao, X.-M.; Su, Y.; Moore, S.; Han, L.-P.; Kiriazis, H.; Lu, Q.; Zhao, W.-B.; Ruze, A.; Fang, B.-B.; Duan, M.-J.; et al. Relaxin Mitigates
Microvascular Damage and Inflammation Following Cardiac Ischemia-Reperfusion. Basic Res. Cardiol. 2019, 114, 30. [CrossRef]
117. Devarakonda, T.; Mauro, A.G.; Guzman, G.; Hovsepian, S.; Cain, C.; Das, A.; Praveen, P.; Hossain, M.A.; Salloum, F.N. B7-33, a
Functionally Selective Relaxin Receptor 1 Agonist, Attenuates Myocardial Infarction–Related Adverse Cardiac Remodeling in
Mice. J. Am. Heart Assoc. 2020, 9, e015748. [CrossRef]
118. Konijnenberg, L.S.F.; Luiken, T.T.J.; Veltien, A.; Uthman, L.; Kuster, C.T.A.; Rodwell, L.; de Waard, G.A.; Kea-te Lindert, M.; Akiva,
A.; Thijssen, D.H.J.; et al. Imatinib Attenuates Reperfusion Injury in a Rat Model of Acute Myocardial Infarction. Basic Res. Cardiol.
2023, 118, 2. [CrossRef]
119. Mondal, N.K.; Behera, J.; Kelly, K.E.; George, A.K.; Tyagi, P.K.; Tyagi, N. Tetrahydrocurcumin Epigenetically Mitigates Mitochon-
drial Dysfunction in Brain Vasculature during Ischemic Stroke. Neurochem. Int. 2019, 122, 120–138. [CrossRef]
120. Walsh, S.R.; Tang, T.Y.; Kullar, P.; Jenkins, D.P.; Dutka, D.P.; Gaunt, M.E. Ischaemic Preconditioning during Cardiac Surgery:
Systematic Review and Meta-Analysis of Perioperative Outcomes in Randomised Clinical Trials. Eur. J. Cardio-Thorac. Surg. 2008,
34, 985–994. [CrossRef]
Cells 2023, 12, 1345 19 of 21

121. Thielmann, M.; Kottenberg, E.; Kleinbongard, P.; Wendt, D.; Gedik, N.; Pasa, S.; Price, V.; Tsagakis, K.; Neuhäuser, M.; Peters,
J.; et al. Cardioprotective and Prognostic Effects of Remote Ischaemic Preconditioning in Patients Undergoing Coronary Artery
Bypass Surgery: A Single-Centre Randomised, Double-Blind, Controlled Trial. Lancet 2013, 382, 597–604. [CrossRef] [PubMed]
122. Zhao, Z.-Q.; Corvera, J.S.; Halkos, M.E.; Kerendi, F.; Wang, N.-P.; Guyton, R.A.; Vinten-Johansen, J. Inhibition of Myocardial
Injury by Ischemic Postconditioning during Reperfusion: Comparison with Ischemic Preconditioning. Am. J. Physiol. Heart Circ.
Physiol. 2003, 285, H579–H588. [CrossRef] [PubMed]
123. Halkos, M.E.; Kerendi, F.; Corvera, J.S.; Wang, N.-P.; Kin, H.; Payne, C.S.; Sun, H.-Y.; Guyton, R.A.; Vinten-Johansen, J.; Zhao,
Z.-Q. Myocardial Protection with Postconditioning Is Not Enhanced by Ischemic Preconditioning. Ann. Thorac. Surg. 2004, 78,
961–969. [CrossRef]
124. Yang, X.M.; Proctor, J.B.; Cui, L.; Krieg, T.; Downey, J.M.; Cohen, M.V. Multiple, Brief Coronary Occlusions during Early
Reperfusion Protect Rabbit Hearts by Targeting Cell Signaling Pathways. J. Am. Coll. Cardiol. 2004, 44, 1103–1110. [CrossRef]
[PubMed]
125. Zhao, Z.Q.; Vinten-Johansen, J. Postconditioning: Reduction of Reperfusion-Induced Injury. Cardiovasc. Res. 2006, 70, 200–211.
[CrossRef]
126. Hausenloy, D.J.; Barrabes, J.A.; Bøtker, H.E.; Davidson, S.M.; Di Lisa, F.; Downey, J.; Engstrom, T.; Ferdinandy, P.; Carbrera-Fuentes,
H.A.; Heusch, G.; et al. Ischaemic Conditioning and Targeting Reperfusion Injury: A 30 Year Voyage of Discovery. Basic Res.
Cardiol. 2016, 111, 70. [CrossRef]
127. Xue, F.; Yang, X.; Zhang, B.; Zhao, C.; Song, J.; Jiang, T.; Jiang, W. Postconditioning the Human Heart in Percutaneous Coronary
Intervention. Clin. Cardiol. 2010, 33, 439–444. [CrossRef]
128. Staat, P.; Rioufol, G.; Piot, C.; Cottin, Y.; Cung, T.T.; L’Huillier, I.; Aupetit, J.-F.; Bonnefoy, E.; Finet, G.; André-Fouët, X.; et al.
Postconditioning the Human Heart. Circulation 2005, 112, 2143–2148. [CrossRef]
129. Mukherjee, P.; Jain, M. Effect of Ischemic Postconditioning during Primary Percutaneous Coronary Intervention for Patients with
ST-Segment Elevation Myocardial Infarction: A Single-Center Cross-Sectional Study. Ann. Card. Anaesth. 2019, 22, 347. [CrossRef]
130. Hahn, J.-Y.; Song, Y.B.; Kim, E.K.; Yu, C.W.; Bae, J.-W.; Chung, W.-Y.; Choi, S.-H.; Choi, J.-H.; Bae, J.-H.; An, K.J.; et al. Ischemic
Postconditioning During Primary Percutaneous Coronary Intervention. Circulation 2013, 128, 1889–1896. [CrossRef]
131. Engstrøm, T.; Kelbæk, H.; Helqvist, S.; Høfsten, D.E.; Kløvgaard, L.; Clemmensen, P.; Holmvang, L.; Jørgensen, E.; Pedersen, F.;
Saunamaki, K.; et al. Effect of Ischemic Postconditioning during Primary Percutaneous Coronary Intervention for Patients with
ST-Segment Elevation Myocardial Infarction: A Randomized Clinical Trial. JAMA Cardiol. 2017, 2, 490–497. [CrossRef]
132. Thuny, F.; Lairez, O.; Roubille, F.; Mewton, N.; Rioufol, G.; Sportouch, C.; Sanchez, I.; Bergerot, C.; Thibault, H.; Cung, T.T.; et al.
Post-Conditioning Reduces Infarct Size and Edema in Patients With ST-Segment Elevation Myocardial Infarction. J. Am. Coll.
Cardiol. 2012, 59, 2175–2181. [CrossRef] [PubMed]
133. Stiermaier, T.; Jensen, J.O.; Rommel, K.P.; De Waha-Thiele, S.; Fuernau, G.; Desch, S.; Thiele, H.; Eitel, I. Combined Intrahospital
Remote Ischemic Perconditioning and Postconditioning Improves Clinical Outcome in St-Elevation Myocardial Infarction:
Long-Term Results of the Lipsia Conditioning Trial. Circ. Res. 2019, 124, 1482–1491. [CrossRef]
134. Heusch, G.; Rassaf, T. Time to Give Up on Cardioprotection?: A Critical Appraisal of Clinical Studies on Ischemic Pre-, Post-, and
Remote Conditioning∗. Circ. Res. 2016, 119, 676–695. [CrossRef] [PubMed]
135. Hausenloy, D.J.; Candilio, L.; Evans, R.; Ariti, C.; Jenkins, D.P.; Kolvekar, S.; Knight, R.; Kunst, G.; Laing, C.; Nicholas, J.; et al.
Remote Ischemic Preconditioning and Outcomes of Cardiac Surgery. N. Eng. J. Med. 2015, 373, 1408–1417. [CrossRef]
136. Meybohm, P.; Bein, B.; Brosteanu, O.; Cremer, J.; Gruenewald, M.; Stoppe, C.; Coburn, M.; Schaelte, G.; Böning, A.; Niemann,
B.; et al. A Multicenter Trial of Remote Ischemic Preconditioning for Heart Surgery. N. Eng. J. Med. 2015, 373, 1397–1407.
[CrossRef] [PubMed]
137. Hausenloy, D.J.; Kharbanda, R.K.; Møller, U.K.; Ramlall, M.; Aarøe, J.; Butler, R.; Bulluck, H.; Clayton, T.; Dana, A.; Dodd, M.; et al.
Effect of Remote Ischaemic Conditioning on Clinical Outcomes in Patients with Acute Myocardial Infarction (CONDI-2/ERIC-
PPCI): A Single-Blind Randomised Controlled Trial. Lancet 2019, 394, 1415–1424. [CrossRef]
138. Ottani, F.; Latini, R.; Staszewsky, L.; Vecchia, L.L.; Locuratolo, N.; Sicuro, M.; Masson, S.; Barlera, S.; Milani, V.; Lombardi, M.; et al.
Cyclosporine A in Reperfused Myocardial Infarction The Multicenter, Controlled, Open-Label CYCLE Trial. J. Am. Coll. Cardiol.
2016, 67, 1415–1427.
139. Cung, T.-T.; Morel, O.; Cayla, G.; Rioufol, G.; Garcia-Dorado, D.; Angoulvant, D.; Bonnefoy-Cudraz, E.; Guérin, P.; Elbaz, M.;
Delarche, N.; et al. Cyclosporine before PCI in Patients with Acute Myocardial Infarction. N. Eng. J. Med. 2015, 373, 1021–1031.
[CrossRef]
140. Atar, D.; Arheden, H.; Berdeaux, A.; Bonnet, J.L.; Carlsson, M.; Clemmensen, P.; Cuvier, V.; Danchin, N.; Dubois-Randé, J.L.;
Engblom, H.; et al. Effect of Intravenous TRO40303 as an Adjunct to Primary Percutaneous Coronary Intervention for Acute
ST-Elevation Myocardial Infarction: MITOCARE Study Results. Eur. Heart J. 2015, 36, 112–119. [CrossRef]
141. Mahaffey, K.W.; Puma, J.A.; Barbagelata, N.A.; Dicarli, M.F.; Leesar, M.A.; Browne, K.F.; Eisenberg, P.R.; Bolli, R.; Casas, A.C.;
Molina-Viamonte, V.; et al. Adenosine as an Adjunct to Thrombolytic Therapy for Acute Myocardial Infarction-Results of a
Multicenter, Randomized, Placebo-Controlled Trial: The Acute Myocardial Infarction STudy of ADenosine (AMISTAD) Trial. J.
Am. Coll. Cardiol. 1999, 34, 1711–1720. [CrossRef] [PubMed]
Cells 2023, 12, 1345 20 of 21

142. Ross, A.M.; Gibbons, R.J.; Stone, G.W.; Kloner, R.A.; Alexander, R.W. A Randomized, Double-Blinded, Placebo-Controlled
Multicenter Trial of Adenosine as an Adjunct to Reperfusion in the Treatment of Acute Myocardial Infarction (AMISTAD-II). J.
Am. Coll. Cardiol. 2005, 45, 1775–1780. [CrossRef]
143. Armstrong, P.W.; The APEX Investigators. Pexelizumab for Acute ST-Elevation Myocardial Infarction in Patients Undergoing
Primary Percutaneous Coronary Intervention A Randomized Controlled Trial. JAMA 2007, 297, 43–51.
144. Lincoff, A.M.; Roe, M.; Aylward, P.; Galla, J.; Rynkiewicz, A.; Guetta, V.; Zelizko, M.; Kleiman, N.; White, H.; McErlean, E.; et al.
Inhibition of Delta-Protein Kinase C by Delcasertib as an Adjunct to Primary Percutaneous Coronary Intervention for Acute
Anterior ST-Segment Elevation Myocardial Infarction: Results of the PROTECTION AMI Randomized Controlled Trial. Eur.
Heart J. 2014, 35, 2516–2523. [CrossRef]
145. Bainey, K.R.; Armstrong, P.W. Ameliorating Reperfusion Injury in STEMI: Dead or Alive? Eur. Heart J. 2014, 35, 2504–2506.
[CrossRef] [PubMed]
146. Thiele, H.; Wöhrle, J.; Hambrecht, R.; Rittger, H.; Birkemeyer, R.; Lauer, B.; Neuhaus, P.; Brosteanu, O.; Sick, P.; Wiemer, M.; et al.
Intracoronary versus Intravenous Bolus Abciximab during Primary Percutaneous Coronary Intervention in Patients with Acute
ST-Elevation Myocardial Infarction: A Randomised Trial. Lancet 2012, 379, 923–931. [CrossRef] [PubMed]
147. Voors, A.A.; Belonje, A.M.S.; Zijlstra, F.; Hillege, H.L.; Anker, S.D.; Slart, R.H.J.A.; Tio, R.A.; van ’T Hof, A.; Jukema, J.W.; Peels,
H.O.J.; et al. A Single Dose of Erythropoietin in ST-Elevation Myocardial Infarction. Eur. Heart J. 2010, 31, 2593–2600. [CrossRef]
148. Ponikowski, P.; Jankowska, E.A. EPO’s Rescue Mission in Acute Myocardial Infarction: Still More Hopes than Evidence. Eur.
Heart J. 2010, 31, 2577–2579. [CrossRef]
149. Heusch, G. Critical Issues for the Translation of Cardioprotection. Circ. Res. 2017, 120, 1477–1486. [CrossRef]
150. Heusch, G.; Gersh, B.J. Is Cardioprotection Salvageable? Circulation 2020, 141, 415–417. [CrossRef]
151. Heusch, G.; Kleinbongard, P.; Rassaf, T. Cardioprotection beyond Infarct Size Reduction. Circ. Res. 2019, 122, 679–680. [CrossRef]
[PubMed]
152. Kloner, R.A. Current State of Clinical Translation of Cardioprotective Agents for Acute Myocardial Infarction. Circ. Res. 2013, 113,
451–463. [CrossRef] [PubMed]
153. Eltzschig, H.K.; Eckle, T. Ischemia and Reperfusion-from Mechanism to Translation. Nat. Med. 2011, 17, 1391–1401. [CrossRef]
[PubMed]
154. Garcia-Dorado, D.; Rodríguez-Sinovas, A.; Ruiz-Meana, M.; Inserte, J. Protection Against Myocardial Ischemia-Reperfusion
Injury in Clinical Practice. Rev. Española Cardiol. 2014, 67, 394–404. [CrossRef]
155. Lehr, H.-A.; Menger, M.D.; Granger, D.N. Ischemia-Reperfusion Injury: Enthusiasm in Laboratory Research but Dilemma in
Clinical Trials? Circulation 1994, 90, 1580. [CrossRef] [PubMed]
156. Dirksen, M.T.; Laarman, G.J.; Simoons, M.L.; Duncker, D.J.G.M. Reperfusion Injury in Humans: A Review of Clinical Trials on
Reperfusion Injury Inhibitory Strategies. Cardiovasc. Res. 2007, 74, 343–355. [CrossRef]
157. Spath, N.B.; Mills, N.L.; Cruden, N.L. Novel Cardioprotective and Regenerative Therapies in Acute Myocardial Infarction: A
Review of Recent and Ongoing Clinical Trials. Fut Cardiol. 2016, 12, 655–672. [CrossRef]
158. Li, Y.; Gao, Y.; Li, G. Preclinical Multi-Target Strategies for Myocardial Ischemia-Reperfusion Injury. Front. Cardiovasc. Med. 2022,
9, 967115. [CrossRef]
159. Lejay, A.; Fang, F.; John, R.; Van, J.A.D.; Barr, M.; Thaveau, F.; Chakfe, N.; Geny, B.; Scholey, J.W. Ischemia Reperfusion Injury,
Ischemic Conditioning and Diabetes Mellitus. J. Mol. Cell Cardiol. 2016, 91, 11–22. [CrossRef]
160. Balakumar, P.; Singh, H.; Singh, M.; Anand-Srivastava, M.B. The Impairment of Preconditioning-Mediated Cardioprotection in
Pathological Conditions. Pharmacol. Res. 2009, 60, 18–23. [CrossRef]
161. Ferdinandy, P.; Schulz, R.; Baxter, G.F. Interaction of Cardiovascular Risk Factors with Myocardial Ischemia/Reperfusion Injury,
Preconditioning, and Postconditioning. Pharmacol. Rev. 2007, 59, 418–458. [CrossRef] [PubMed]
162. Boengler, K.; Schulz, R.; Heusch, G. Loss of Cardioprotection with Ageing. Cardiovasc. Res. 2009, 83, 247–261. [CrossRef]
[PubMed]
163. Querio, G.; Geddo, F.; Antoniotti, S.; Gallo, M.P.; Penna, C. Sex and Response to Cardioprotective Conditioning Maneuvers. Front.
Physiol. 2021, 12, 667961. [CrossRef] [PubMed]
164. Rossello, X.; Yellon, D.M. Cardioprotection: The Disconnect between Bench and Bedside. Circulation 2016, 134, 574–575. [CrossRef]
[PubMed]
165. Sato, M.; Engelman, R.M.; Otani, H.; Maulik, N.; Rousou, J.A.; Flack, J.E.; Deaton, D.W.; Das, D.K. Myocardial Protection
by Preconditioning of Heart With Losartan, an Angiotensin II Type 1–Receptor Blocker. Circulation 2000, 102 (Suppl. S3),
Iii-346–Iii-351. [CrossRef]
166. Hu, J.; Lu, Y. Statin and Myocardial Ischemia-Reperfusion Injury. Int. J. Cardiol. 2016, 222, 988. [CrossRef] [PubMed]
167. Bienvenu, L.A.; Maluenda, A.; McFadyen, J.D.; Searle, A.K.; Yu, E.; Haller, C.; Chaikof, E.L.; Peter, K.; Wang, X. Combined
Antiplatelet/Anticoagulant Drug for Cardiac Ischemia/Reperfusion Injury. Circ. Res. 2020, 127, 1211–1213. [CrossRef]
168. Wu, J.; Cai, W.; Du, R.; Li, H.; Wang, B.; Zhou, Y.; Shen, D.; Shen, H.; Lan, Y.; Chen, L.; et al. Sevoflurane Alleviates Myocardial
Ischemia Reperfusion Injury by Inhibiting P2X7-NLRP3 Mediated Pyroptosis. Front. Mol. Biosci. 2021, 8, 768594. [CrossRef]
169. Wang, B.; Wu, Q.; Liao, J.; Zhang, S.; Liu, H.; Yang, C.; Dong, Q.; Zhao, N.; Huang, Z.; Guo, K.; et al. Propofol Induces
Cardioprotection against Ischemia-Reperfusion Injury via Suppression of Transient Receptor Potential Vanilloid 4 Channel. Front.
Pharmacol. 2019, 10, 1150. [CrossRef]
Cells 2023, 12, 1345 21 of 21

170. Fordyce, C.B.; Gersh, B.J.; Stone, G.W.; Granger, C.B. Novel Therapeutics in Myocardial Infarction: Targeting Microvascular
Dysfunction and Reperfusion Injury. Trends Pharmacol. Sci. 2015, 36, 605–616. [CrossRef]
171. Zicola, E.; Arrigo, E.; Mancardi, D. H2S Pretreatment Is Promigratory and Decreases Ischemia/Reperfusion Injury in Human
Microvascular Endothelial Cells. Oxid. Med. Cell Longev. 2021, 2021, 8886666. [CrossRef] [PubMed]
172. Darwish, I.; Liles, W.C. Emerging Therapeutic Strategies to Prevent Infection-Related Microvascular Endothelial Activation and
Dysfunction. Virulence 2013, 4, 572–582. [CrossRef] [PubMed]
173. Heusch, G. The Coronary Circulation as a Target of Cardioprotection. Circ. Res. 2016, 118, 1643–1658. [CrossRef] [PubMed]
174. Hausenloy, D.J.; Chilian, W.; Crea, F.; Davidson, S.M.; Ferdinandy, P.; Garcia-Dorado, D.; Van Royen, N.; Schulz, R.; Heusch, G.
The Coronary Circulation in Acute Myocardial Ischaemia/Reperfusion Injury: A Target for Cardioprotection. Cardiovasc. Res.
2019, 115, 1143–1155. [CrossRef]
175. Atar, D.; Petzelbauer, P.; Schwitter, J.; Huber, K.; Rensing, B.; Kasprzak, J.D.; Butter, C.; Grip, L.; Hansen, P.R.; Süselbeck, T.; et al.
Effect of Intravenous FX06 as an Adjunct to Primary Percutaneous Coronary Intervention for Acute ST-Segment Elevation
Myocardial Infarction. Results of the F.I.R.E. (Efficacy of FX06 in the Prevention of Myocardial Reperfusion Injury) Trial. J. Am.
Coll. Cardiol. 2009, 53, 720–729. [CrossRef]
176. Hallén, J.; Petzelbauer, P.; Schwitter, J.; Geudelin, B.; Buser, P.; Atar, D. Impact of Time to Therapy and Presence of Collaterals on
the Efficacy of FX06 in Acute ST Elevation Myocardial Infarction: A Substudy of the F.I.R.E., the Efficacy of FX06 in the Prevention
of Myocardial Reperfusion Injury Trial. EuroIntervention 2010, 5, 946–952. [CrossRef]
177. Wolf, T.; Kann, G.; Becker, S.; Stephan, C.; Brodt, H.R.; de Leuw, P.; Grünewald, T.; Vogl, T.; Kempf, V.A.J.; Keppler, O.T.; et al.
Severe Ebola Virus Disease with Vascular Leakage and Multiorgan Failure: Treatment of a Patient in Intensive Care. Lancet 2015,
385, 1428–1435. [CrossRef]
178. Adam, E.H.; Schmid, B.; Sonntagbauer, M.; Kranke, P.; Zacharowski, K.; Meybohm, P. Fibrin-Derived Peptide Bβ15-42 (FX06) as
Salvage Treatment in Critically Ill Patients with COVID-19-Associated Acute Respiratory Distress Syndrome. Crit. Care 2020, 24,
574. [CrossRef]
179. Kloka, J.; Friedrichson, B.; Dauth, S.; Foldenauer, A.C.; Bulczak-Schadendorf, A.; Vehreschild, M.J.G.T.; Matos, F.M.; Riera-Mestre,
A.; van Asselt, A.D.I.; de Robertis, E.; et al. Potential of FX06 to Prevent Disease Progression in Hospitalized Non-Intubated
COVID-19 Patients-the Randomized, EU-Wide, Placebo-Controlled, Phase II Study Design of IXION. Trials 2022, 23, 688.
[CrossRef]
180. Bergougnan, L.; Armani, S.; Golor, G.; Tardat, A.; Vitse, O.; Hurbin, F.; Scemama, M.; Poitiers, F.; Radzik, D.; Gaudin, C.; et al.
First-in-Human Study of the Safety, Tolerability, Pharmacokinetics and Pharmacodynamics of Single and Multiple Oral Doses of
SAR247799, a Selective G-Protein-Biased Sphingosine-1 Phosphate Receptor-1 Agonist for Endothelial Protection. Br. J. Clin.
Pharmacol. 2021, 87, 598–611. [CrossRef]
181. Bell, R.M.; Bøtker, H.E.; Carr, R.D.; Davidson, S.M.; Downey, J.M.; Dutka, D.P.; Heusch, G.; Ibanez, B.; Macallister, R.; Stoppe,
C.; et al. 9th Hatter Biannual Meeting: Position Document on Ischaemia/Reperfusion Injury, Conditioning and the Ten
Commandments of Cardioprotection. Basic Res. Cardiol. 2016, 111, 41. [CrossRef] [PubMed]
182. Davidson, S.M.; Ferdinandy, P.; Andreadou, I.; Bøtker, H.E.; Heusch, G.; Ibáñez, B.; Ovize, M.; Schulz, R.; Yellon, D.M.; Hausenloy,
D.J.; et al. Multitarget Strategies to Reduce Myocardial Ischemia/Reperfusion Injury: JACC Review Topic of the Week. J. Am. Coll.
Cardiol. 2019, 73, 89–99. [CrossRef] [PubMed]
183. Bellis, A.; di Gioia, G.; Mauro, C.; Mancusi, C.; Barbato, E.; Izzo, R.; Trimarco, B.; Morisco, C. Reducing Cardiac Injury during
St-Elevation Myocardial Infarction: A Reasoned Approach to a Multitarget Therapeutic Strategy. J. Clin. Med. 2021, 10, 2968.
[CrossRef] [PubMed]

Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual
author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to
people or property resulting from any ideas, methods, instructions or products referred to in the content.