Breakthroughs of ultrasound-targeted microbubble destruction in treating myocardial ischemia-reperfusion injury: from angiogenesis regulation to precise inflammation suppression

Abstract

Myocardial ischemia-reperfusion injury (MIRI), a frequent complication in acute myocardial infarction (AMI) treatment, arises from complex mechanisms including oxidative stress, inflammation, and mitochondrial dysfunction, which impair myocardial repair and recovery. Current therapies for MIRI offer limited efficacy and raise safety concerns, highlighting the need for innovative and precise treatment strategies in cardiovascular research. Ultrasound-targeted microbubble destruction (UTMD) is a promising therapeutic approach that enhances drug delivery precision to the myocardium. By utilizing ultrasound cavitation and nanodrug delivery, UTMD overcomes microvascular barriers, significantly improving drug bioavailability and therapeutic outcomes. It has demonstrated potential in modulating the hypoxia-inducible factor-1α/vascular endothelial growth factor (HIF-1α/VEGF) pathway to promote angiogenesis and enhance myocardial perfusion. In addition, it inhibits NOD-like receptor protein 3 (NLRP3) inflammasome activation, thereby reducing inflammatory responses and protecting the myocardium from reperfusion damage. The integration of radiomics and artificial intelligence (AI) further advances MIRI diagnosis and treatment. Real-time monitoring of myocardial blood flow and microcirculatory perfusion, combined with AI-driven image analysis, enables accurate assessment of myocardial injury and therapeutic efficacy, supporting personalized and precise therapy. Moreover, multi-omics technologies—such as single-cell RNA sequencing, proteomics, and metabolomics—combined with UTMD provide deeper insights into its therapeutic mechanisms, laying a robust foundation for clinical translation. This review summarizes recent progress in UTMD-based therapies for MIRI, emphasizing their roles in angiogenesis, immune regulation, precision diagnostics, and multi-omics analysis. It highlights new perspectives for future research and clinical applications in the management of MIRI.

1. Introduction

Myocardial ischemia–reperfusion injury (MIRI) is a secondary complication commonly observed in patients with acute myocardial infarction (AMI) following percutaneous coronary intervention (PCI) or thrombolytic therapy. The development of MIRI involves a complex pathological cascade that not only impairs myocardial tissue regeneration but also significantly elevates the risk of heart failure (HF) and long–term mortality (Jiang et al. 2025). Despite substantial advances in basic and clinical research in recent years, effective therapeutic strategies remain limited, and MIRI continues to pose a major challenge in AMI management (Figure 1).

Figure 1.

Pathological mechanisms of MIRI, drawn by the authors (Created by BioRender).

Current clinical approaches to MIRI suffer from limited precision and low drug delivery efficiency (She et al. 2024). Ultrasound–targeted microbubble destruction (UTMD) has recently emerged as a novel precision therapy. By combining ultrasound–induced cavitation with targeted drug delivery, UTMD enhances drug accumulation in ischemic myocardial regions while minimizing systemic side effects, thereby offering a promising avenue for MIRI treatment (Zhen et al. 2025). In contrast to traditional strategies–such as antioxidant therapy, anti–inflammatory agents, and vascular function enhancement–UTMD exploits the controllable dynamics of microbubbles via ultrasound to facilitate the targeted delivery of nanodrugs into myocardial tissues. Moreover, it can be integrated with radiomics and multi–omics analyzes to support precision medicine (Zhang et al. 2024). This review systematically summarizes the mechanisms and recent advancements of UTMD in MIRI treatment, with a focus on its applications in promoting angiogenesis, modulating inflammation, and enabling precision therapy.

UTMD represents an innovative therapeutic modality with distinct advantages (Figure 2) (Zhang et al. 2024). First, the ultrasound cavitation effect significantly improves drug permeability across the microvascular barrier. Ultrasound induces localized high–energy activity within microbubbles, transiently increasing capillary permeability. At an ultrasound intensity of 0.8 MPa, endothelial gaps can expand up to 150 nm, facilitating the efficient translocation of nanodrugs across the microvasculature into myocardial tissues (Klibanov 2006). Second, UTMD in combination with nanocarriers–such as poly(lactic–co–glycolic acid) (PLGA), liposomes, and gold nanoparticles–enhances both drug precision and bioavailability. These nanocarriers can be functionalized with targeting ligands (e.g. RGD peptides, antibodies) to further improve myocardial accumulation, with targeting efficiency increasing by 3.2 ± 0.5-fold. Additionally, ultrasound–mediated drug release can be precisely controlled, achieving triggered release rates as high as 92.7 ± 3.1% (Phillips et al. 2011). UTMD also enables integration with ultrasound radiomics to achieve real–time imaging–guided therapy. Microbubbles act as contrast agents, providing dual functionality in both diagnosis and treatment. At a contrast agent concentration of 5 × 10⁸ bubbles/mL, the signal–to–noise ratio improves by 18.3 dB (Klibanov 2006). Furthermore, ultrasound–guided microbubble–mediated delivery has been shown to effectively modulate the hypoxia–inducible factor-1α/vascular endothelial growth factor (HIF-1α/VEGF) signaling axis, increasing VEGF expression by 3.8 ± 0.6-fold and promoting neovascularization. Concurrently, UTMD suppresses activation of the NOD–like receptor protein 3 (NLRP3) inflammasome, reducing interleukin-1β (IL-1β) levels by 62.4 ± 5.1%, thereby attenuating myocardial damage (Phillips et al. 2011).

Figure 2.

Role of the NLRP3 inflammasome in MIRI, drawn by the authors (Created by BioRender).

The therapeutic mechanisms of UTMD in MIRI primarily involve several key pathways. First, UTMD enhances HIF-1α/VEGF axis activity by delivering HIF-1α stabilizers (e.g. dimethyloxalylglycine [DMOG], FG−4592 [Roxadustat]) or VEGF mRNA, thereby promoting angiogenesis and improving perfusion in ischemic myocardial regions (Bai et al. 2024; Jiang et al. 2025). Second, UTMD facilitates the targeted delivery of NLRP3 inhibitors (e.g. MCC950), which effectively suppress NLRP3 inflammasome activation, reduce inflammatory responses, and enhance cardiomyocyte survival (Bai et al. 2024). Additionally, when integrated with radiomics and artificial intelligence (AI), UTMD enables precision diagnosis and therapeutic evaluation in MIRI. Through real–time monitoring of myocardial blood flow and the use of AI–driven algorithms to analyze microcirculatory perfusion and tissue characteristics, UTMD supports the development of individualized treatment strategies (Jiang et al. 2025). Furthermore, advances in modern biomedical technologies have elevated multi–omics approaches–including single–cell RNA sequencing (scRNA–seq), proteomics, and metabolomics–as critical tools for unraveling the molecular underpinnings of MIRI. By integrating UTMD with multi–omics data, researchers can explore its regulatory effects on gene expression, protein function, and metabolic networks, thereby establishing a theoretical basis for precision MIRI therapies (Jiang et al. 2025; Chen et al. 2025).

Despite ongoing progress, MIRI remains a significant obstacle in cardiovascular therapy, with existing treatments often lacking both specificity and efficacy (Li et al. 2019). As an emerging targeted drug delivery system (Jiang et al. 2025), UTMD offers a breakthrough approach by synergizing ultrasound cavitation, nanodrug engineering (e.g. ROS–responsive hydrogels, neutrophil extracellular trap–mediated targeting), and advanced radiomics/AI tools (Zhang et al. 2024; Jiang et al. 2025; Zhen et al. 2025). In the future, with the continued advancement of multi–omics technologies (e.g. dynamic transcriptomics and metabolomics) and the expansion of personalized medicine, UTMD is poised to become a cornerstone of cardiovascular precision therapy, enabling targeted modulation of key signaling pathways such as S100a8/a9-TLR4/ERK and RIPK3-RAGE/CaMKII.

2. Pathological mechanisms of MIRI

2.1. Specific MIRI lesions and the mechanisms of UTMD

The therapeutic value of UTMD in treating MIRI lies in the high complementarity between its physical mechanisms and the pathophysiological processes of MIRI. The cavitation effect enables the reversible opening of endothelial barriers, mechanical stimuli modulate vascular function, and nanocarrier systems facilitate precise drug delivery. As our understanding of MIRI pathogenesis deepens and UTMD technology continues to advance, this integrated physical–biological therapeutic strategy holds great promise to become a crucial component of precision cardiovascular medicine in the future.

One of the most prominent manifestations of MIRI is microvascular dysfunction (MVO), characterized by the failure of myocardial tissue to achieve effective reperfusion despite the reopening of the occluded coronary artery. This so–called ‘no–reflow’ phenomenon arises from multiple factors, including microthrombus formation caused by platelet and fibrin aggregation obstructing capillaries; endothelial cell edema induced by ischemia, which narrows the vascular lumen; and inflammatory responses that promote leukocyte adhesion and subsequent neutrophil–platelet aggregation, leading to microvascular blockage (Long et al. 2025; Liu et al. 2025). The fundamental physical mechanism of UTMD is the acoustic cavitation effect–a dynamic process in which microbubbles oscillate, expand, and violently collapse under ultrasonic exposure. The energy released during this process can act on MIRI–associated microvascular lesions in several ways. For instance, microstreaming shear forces generated by stable cavitation can disperse neutrophil–platelet aggregates within capillaries; microjets formed during inertial cavitation can impact and clear microvessels blocked by cellular debris; moreover, the transient vascular dilation induced by cavitation can enhance red blood cell deformability and capillary perfusion (Li and Du 2021).

Another core pathological alteration in MIRI is the impairment of endothelial barrier function, leading to increased vascular permeability and tissue edema. The integrity of the endothelial barrier depends on tight junctions, adherens junctions, and the glycocalyx layer covering the luminal surface of endothelial cells. When the glycocalyx is shed (with syndecan−1 serving as a biomarker), the tight junctions between endothelial cells become disrupted, resulting in extravasation of plasma fluid and proteins, which in turn causes myocardial tissue edema and further compresses microvessels, exacerbating ischemic damage (Wu et al. 2025). The mechanical forces generated by UTMD not only serve to transiently open vascular barriers but also directly influence endothelial cell biological behavior. The shear stress produced by cavitation can activate mechanosensitive ion channels (such as TRPV4) in endothelial cells, subsequently upregulating eNOS expression and NO production. This process improves microvascular tone and suppresses inflammatory responses, thereby contributing to vascular protection and functional recovery (Deng 2013; Wang et al. 2014).

During the processes of sterile inflammation and cell death, MIRI involves several critical pathological events, including overactivation of the NLRP3 inflammasome, pyroptosis, and abnormal opening of the mitochondrial permeability transition pore (mPTP) (Huang et al. 2024; Wei et al. 2025). Through its distinctive mechanobiological signaling and targeted delivery capabilities, UTMD (Ultrasound–Targeted Microbubble Destruction) can exert multidimensional regulatory effects on these lesions. Specifically, the microstreaming shear forces generated by cavitation can directly inhibit NLRP3 oligomerization, while simultaneously activating mechanosensitive pathways such as integrin–FAK–Akt, which promote the phenotypic polarization of macrophages from the pro–inflammatory M1 type to the reparative M2 type. In addition, UTMD can precisely deliver agents such as MCC950 (an NLRP3 inhibitor) or microRNAs like miR−223 to block the pyroptotic cascade. Moreover, UTMD can either deliver cyclosporine A at optimal timing or directly modulate mitochondrial membrane tension through mechanical stimuli, thereby regulating the temporal dynamics of mPTP opening. Collectively, these effects enable temporal control of cell survival and death across various post–reperfusion phases, ranging from minutes to up to 72 hours (Lin et al. 2022).

In the arrhythmogenic substrate phase of MIRI, pathological alterations such as increased electrical conduction heterogeneity, autonomic nerve remodeling, and abnormal calcium handling play critical roles in promoting post–reperfusion arrhythmias. The therapeutic strategy of UTMD in this context emphasizes precision modulation under strict safety constraints. By carefully confining ultrasound parameters–particularly the mechanical index (MI)—within a defined ‘therapeutic window’ that enhances microcirculation without directly stimulating cardiomyocytes, UTMD avoids excessive activation of mechanosensitive cation channels, thereby preventing the occurrence of afterdepolarizations and new–onset arrhythmias. Concurrently, UTMD enables targeted delivery of agents such as connexin−43 modulators or nerve growth factor (NGF) inhibitors, which help reverse electrical conduction abnormalities and sympathetic nerve remodeling at their molecular origins. Furthermore, by integrating ECG–gated ultrasound emission, real–time electrocardiographic monitoring, and ultrasound elastography–based safety assessment, UTMD ensures that treatment improves microvascular perfusion and myocardial viability without compromising electrical stability. This capacity for precise mapping and targeted intervention against specific pathological substrates transforms UTMD from a simple drug–delivery technique into a biophysical regulation platform capable of temporal, multi–target reconstruction of the myocardial microenvironment and electrophysiological stability.

2.2. Molecular–level damage triggered by MIRI

MIRI refers to the paradoxical exacerbation of myocardial damage that occurs upon the restoration of blood flow following a period of ischemia. This process involves a multitude of molecular mechanisms, with oxidative stress, inflammatory cascades, and mitochondrial dysfunction being the primary contributors (Chen et al. 2025). During reperfusion, there is a burst in the generation of reactive oxygen species (ROS) within cardiomyocytes, including superoxide anions, hydroxyl radicals, and hydrogen peroxide. These ROS induce lipid peroxidation, protein and DNA oxidation, and compromise the structural integrity and functional viability of cellular membranes, ultimately leading to cellular dysfunction and death (Hu et al. 2023; Chen et al. 2025). Oxidative stress serves as a critical initiating event in MIRI, amplifying myocardial injury through multiple interrelated pathways (Leng et al. 2025; Li et al. 2025).

Meanwhile, reperfusion activates the complement system, particularly components such as C1q, C3a, and C5a, which facilitate the recruitment and infiltration of inflammatory cells, including neutrophils and macrophages (Welt et al. 2024; Sun et al. 2025). These infiltrating immune cells release large quantities of pro–inflammatory cytokines and proteolytic enzymes, such as TNF-α, IL-1β, and matrix metalloproteinases, which further aggravate myocardial tissue damage (Zhang et al. 2024). The ensuing inflammatory response not only causes direct cardiomyocyte injury and death but also disrupts endothelial cell function, increases vascular permeability, and contributes to myocardial edema and functional deterioration (Welt et al. 2024; Sun et al. 2025). Moreover, reperfusion induces excessive calcium influx into cardiomyocytes, resulting in mitochondrial calcium overload. This triggers the opening of the mitochondrial permeability transition pore (mPTP), leading to the collapse of mitochondrial membrane potential, impaired ATP synthesis, and cellular energy depletion. Pro–apoptotic factors such as cytochrome c are released into the cytosol, initiating caspase–dependent apoptotic pathways and ultimately culminating in cardiomyocyte death. Mitochondrial dysfunction thus plays a central role in MIRI pathogenesis, with the extent of mitochondrial injury directly determining myocardial survival and functional recovery (Sun et al. 2025).

2.3. Role of the NLRP3 inflammasome in MIRI

The NLRP3 inflammasome is a key component of the innate immune system and plays a central role in mediating the inflammatory response during MIRI. As a core regulatory of innate immunity, the NLRP3 inflammasome is critically involved in the pathogenesis of cardiovascular diseases (CVDs) and metabolic syndrome (MS). In CVDs (such as atherosclerosis and HF), tissue damage leads to aberrant activation of NLRP3, triggering the release of IL-1β and IL−18, and inducing pyroptosis, thereby amplifying the inflammatory cascade (Marchetti et al. 2014). In MS and its complications, chronic metabolic inflammation (metaflammation) driven by high–fat and high–sugar diets activates NLRP3 through multiple molecular mechanisms (Mastrocola et al. 2018). Therefore, NLRP3 serves as a ‘common pathway’ linking metabolic dysregulation to cardiovascular injury. Its targeted inhibition expands therapeutic potential from CVDs to MS, offering novel avenues for managing inflammation–associated pathologies (Toldo et al. 2022). During reperfusion, danger–associated molecular patterns (DAMPs) such as ROS, calcium overload, and ATP depletion initiate NLRP3 inflammasome activation, leading to the assembly of the NLRP3-ASC (apoptosis–associated speck–like protein containing a CARD)-caspase−1 complex (Figure 2) (Freeman and Swartz 2020; Cheng 2021; Welt et al. 2024). Upon sensing intracellular or extracellular stress, NLRP3 undergoes conformational changes and recruits the adapter protein ASC via PYD domain interactions. ASC then engages and activates pro–caspase−1 (Feng et al. 2025). Activated caspase−1 cleaves pro–IL-1β and pro–IL−18 into their mature, bioactive forms, which are subsequently secreted to propagate the inflammatory response (Freeman and Swartz 2020; Liu et al. 2024) (Figure 2). These cytokines not only induce apoptosis and pyroptosis in cardiomyocytes but also stimulate chemokines such as CXCL1 and CCL2, promoting the recruitment of neutrophils, monocytes, and macrophages into the ischemic myocardium, thus further exacerbating the inflammatory milieu (Li et al. 2025; Feng et al. 2025). IL-1β also upregulates adhesion molecules, including intercellular adhesion molecule−1 (ICAM−1) and vascular cell adhesion molecule−1 (VCAM−1), enhancing leukocyte adhesion and transmigration into inflamed tissue, thereby amplifying myocardial injury (Liu et al. 2024).

Notably, the activation of NLRP3 during MIRI displays tissue specificity. During the ischemic phase, hypoxia leads to mitochondrial ROS accumulation, initiating NLRP3 priming. Upon reperfusion, abrupt restoration of blood flow leads to calcium overload and pH shifts, promoting inflammasome assembly via K⁺ efflux (Chen et al. 2024). Small–molecule inhibitors targeting NLRP3 are an emerging area of interest. These compounds typically bind to the NACHT domain of NLRP3, blocking its ATP–binding capacity. In diabetic MIRI models, the selective NLRP3 inhibitor CY−09 significantly improved insulin resistance (reducing HOMA–IR by 40%) and alleviated myocardial injury (Mastrocola et al. 2018). Furthermore, various plant–derived bioactive compounds have demonstrated potential in suppressing NLRP3 activation indirectly by activating the Nrf2-mediated antioxidant pathway. Clinical trials have shown that daily supplementation with 200 mg of anthocyanins in patients with coronary artery disease can reduce circulating IL−18 levels by approximately 30% (Pereira et al. 2024).

In addition to cytokine production, excessive NLRP3 activation induces pyroptosis, a lytic form of programmed cell death marked by inflammation (Zhao et al. 2024; Li et al. 2025). During pyroptosis, caspase−1 cleaves gasdermin D (GSDMD), releasing its N-terminal fragment (GSDMD-N), which oligomerizes and forms membrane pores of 10–20 nm diameter. This results in the release of cytoplasmic contents, including IL-1β, IL−18, ATP, and HMGB1, into the extracellular space (Zhao et al. 2024; Li et al. 2025). These damage–associated molecular patterns (DAMPs) can further activate NLRP3 in adjacent cells, creating a feed–forward loop that intensifies myocardial injury (Feng et al. 2025). Currently, NLRP3 inhibitors such as MCC950 have shown substantial cardioprotective effects in preclinical studies, including reduction of infarct size, improvement of left ventricular ejection fraction (LVEF), and attenuation of myocardial fibrosis (Li et al. 2025; Feng et al. 2025). However, clinical translation remains challenging. Long–term use of MCC950 may compromise host defense against infections, and its specific inhibition of NLRP3 could disrupt physiological inflammatory responses. Therefore, future research should focus on structural optimization or the development of more precise NLRP3-targeted therapies to balance efficacy and safety (Feng et al. 2025).

2.4. The critical role of the HIF-1α/VEGF axis in myocardial repair

HIF-1α serves as a key transcriptional regulator of cellular responses to hypoxic stress during MIRI. It induces the expression of VEGF, thereby promoting angiogenesis and facilitating myocardial repair (Rakhshan et al. 2022; Ge 2024). In the early phase of ischemia, HIF-1α expression is transiently upregulated. However, following reperfusion, elevated oxidative stress accelerates HIF-1α degradation, resulting in insufficient VEGF production, impaired neovascularization, and compromised myocardial regeneration (Zhang et al. 2024). Preclinical studies have shown that HIF-1α expression levels positively correlate with myocardial microvascular density and improvements in cardiac function in MIRI models (Jiang et al. 2025). Therefore, enhancing HIF-1α stability and promoting VEGF–mediated angiogenesis represent pivotal strategies for myocardial repair.

Current strategies to modulate HIF-1α levels primarily include the use of HIF-1α stabilizers, gene therapy, and nanodrug delivery systems. Pharmacological stabilizers of HIF-1α, such as dimethyloxalylglycine (DMOG) and FG−4592 (Roxadustat), inhibit prolyl hydroxylase domain (PHD) enzymes responsible for HIF-1α degradation, thereby enhancing HIF-1α accumulation and upregulating VEGF expression. Although these agents have demonstrated cardioprotective effects in animal studies, concerns regarding their safety and long–term effects currently limit their clinical application (Deng et al. 2024). Gene therapy approaches–utilizing viral vectors (e.g. adenovirus, lentivirus) or non–viral carriers (e.g. liposomes, nanoparticles)—aim to deliver HIF-1α or VEGF genes directly into ischemic myocardium to enhance localized gene expression. However, viral vectors may elicit immune responses, and the transfection efficiency of non–viral systems still requires significant optimization (Deng et al. 2024).

As a novel precision delivery platform, UTMD enhances vascular permeability through ultrasound–induced cavitation, facilitating the targeted delivery of HIF-1α-associated drugs or genes to ischemic myocardial regions. Recent studies have demonstrated that UTMD–mediated delivery of VEGF mRNA or HIF-1α stabilizers significantly increases myocardial microvascular density, reduces infarct size, and improves cardiac functional recovery . Intriguingly, HIF-1α has also been shown to interact with the NLRP3 inflammasome. Stabilization of HIF-1α suppresses NLRP3 activation and reduces the secretion of pro–inflammatory cytokines such as IL-1β and IL−18, thereby attenuating the inflammatory response (Feng et al. 2025). These findings suggest that the angiogenic and anti–inflammatory effects of HIF-1α may act synergistically to improve outcomes in MIRI, providing new insights for therapeutic development.

In summary, the pathophysiology of MIRI is multifaceted, involving oxidative stress, inflammation, mitochondrial dysfunction, pyroptosis, and impaired angiogenesis (Zhang et al. 2025). Oxidative stress is a central event in the early phase of MIRI, triggering inflammatory cascades and mitochondrial injury, thereby exacerbating cardiomyocyte damage (Zhang et al. 2025). The excessive activation of the NLRP3 inflammasome plays a critical role in this process by promoting IL-1β and IL−18 release and inducing pyroptosis. Targeted inhibition of the NLRP3 inflammasome has emerged as an effective strategy to mitigate myocardial inflammation and injury (Huang et al. 2024). Meanwhile, the HIF-1α/VEGF axis is essential for promoting post–ischemic myocardial repair; however, oxidative stress–induced HIF-1α degradation limits its therapeutic potential (Zhang et al. 2025). Enhancing HIF-1α stability and augmenting VEGF–mediated neovascularization are thus crucial for restoring myocardial function. In recent years, UTMD has shown promising therapeutic potential in MIRI by enabling the precise delivery of HIF-1α-related therapeutics and promoting targeted inhibition of NLRP3 inflammasome activation. This dual action both enhances angiogenesis and mitigates inflammation (Huang et al. 2024). Future research should focus on optimizing the integration of UTMD with radiomics and multi–omics platforms to accelerate clinical translation and advance the field of precision cardiovascular medicine.

3. Technical advantages of UTMD

UTMD combines the ultrasound–induced cavitation effect with the targeted delivery capabilities of microbubbles, offering distinct technical advantages in the treatment of MIRI. First, UTMD leverages the active targeting properties of targeted microbubbles (TMBs), which can selectively bind to overexpressed inflammatory markers (e.g. ICAM−1 or VCAM−1) in injured myocardial tissue. Upon ultrasound activation, the cavitation effect induces microbubble rupture, triggering localized drug release (Wang et al. 2025; Jiang et al. 2025). This mechanism enables precise delivery of therapeutic agents and significantly increases drug concentration at the site of injury (Jiang et al. 2025). For example, a neutrophil–mediated nanoparticle delivery system has been shown to target the sarcoplasmic reticulum (SR) of damaged cardiomyocytes through an ‘intercellular network.’ Additionally, lactylation–modified Serpina3k enhances the stability of cardioprotective proteins via paracrine mechanisms (Wang et al. 2025), indirectly supporting the targeted delivery benefits conferred by UTMD.

Second, the cavitation effect of ultrasound can transiently increase the permeability of cell membranes by forming nanoscale pores, thereby facilitating transmembrane drug transport and improving intracellular drug uptake. This enhances both drug bioavailability and therapeutic efficacy. For instance, nanoparticles loaded with a SERCA activator and delivered via neutrophil carriers effectively restored calcium homeostasis and reduced cardiomyocyte apoptosis in MIRI models (Wang et al. 2025). Similarly, poly(amino acid)-based hydrogels (PMA/FTY720) utilizing ROS–responsive release mechanisms demonstrated synergistic antioxidant and anti–inflammatory effects (Onasanya et al. 2025), which complement UTMD's capacity for controlled and localized drug release. Furthermore, the localized nature of UTMD minimizes systemic drug distribution and reduces off–target toxicity. Compared to conventional intravenous delivery, targeted systems (e.g. SR–localized nanoparticles) have been shown to reduce the required therapeutic dose to just one–fifth, while avoiding adverse effects on healthy tissues (Jiang et al. 2025). Notably, local delivery of the itaconate derivative 4-octyl itaconate (4-OI) was found to promote angiogenesis via activation of the ERK signaling pathway and significantly attenuate systemic inflammation (Yang et al. 2025).

Finally, UTMD can be integrated with other therapeutic modalities to achieve synergistic, multi–mechanistic effects. For example, coordinated regulation of protein lactylation (such as K351 lactylation of Serpina3k) has been shown to enhance anti–apoptotic outcomes. Additionally, ROS–responsive materials (e.g. PMA hydrogels) allow for dynamic and stimuli–responsive drug release (Onasanya et al. 2025). This multifaceted intervention strategy enables simultaneous targeting of multiple pathological mechanisms underlying MIRI, including oxidative stress, calcium overload, and inflammatory cascades (Wang et al. 2025; Onasanya et al. 2025).

3.1. Mechanism of UTMD and drug delivery pathways

UTMD facilitates efficient drug delivery by integrating the ultrasound cavitation effect with TMB technology (Figure 3) (Zheng et al. 2023). The cavitation effect refers to the vigorous oscillation of microbubbles under ultrasound exposure, generating localized high pressure (>5000 kPa), extreme temperatures (>5000 K), and high–velocity microjets (>200 m/s). These forces disrupt the microvascular barrier and transiently increase endothelial permeability, thereby facilitating the penetration of therapeutic agents into ischemic myocardial tissue (Yang et al. 2022; Jiang et al. 2025). Upon ultrasound stimulation, microbubbles undergo oscillation, expansion, and eventual rupture due to alternating high–and low–pressure phases (Doustikhah et al. 2024; Zhao et al. 2025). This mechanical disruption temporarily enhances the permeability of both vascular and cellular membranes, thereby promoting drug passage through the microvascular barrier and enabling direct action on target myocardial tissue (Zheng et al. 2023). The cavitation effect not only improves drug penetration but also significantly enhances delivery specificity (Zheng et al. 2023).

Figure 3.

Mechanism of action of the UTMD, drawn by the authors (Created by BioRender).

To further improve targeting efficiency, UTMD utilizes microbubbles functionalized with ligands such as integrin αvβ3, RGD peptides, or specific antibodies to facilitate binding to ischemic myocardial tissues (Lu et al. 2023). Upon ultrasound activation, these functionalized microbubbles rupture, releasing their therapeutic payload locally, thus achieving high site–specific drug concentrations while minimizing off–target effects (Sun et al. 2022; Yang et al. 2022). In addition to enhancing targeted accumulation, UTMD modulates key biological pathways involved in MIRI pathophysiology (Sun et al. 2022; Jiang et al. 2025). Notably, UTMD upregulates HIF-1α expression in ischemic myocardium (increased by 3.5 ± 0.6-fold), thereby boosting VEGF mRNA expression (increased by 4.2 ± 0.7-fold), which promotes angiogenesis and improves tissue perfusion (Zheng et al. 2023).

Furthermore, UTMD has been employed to deliver NLRP3 inflammasome inhibitors (e.g. MCC950) or miRNAs targeting components of the NLRP3 signaling pathway, thereby mitigating inflammatory responses associated with MIRI (Yang et al. 2022). This approach has demonstrated significant reductions in NLRP3 protein expression (by 63.4 ± 5.1%) and subsequent decreases in the secretion of IL-1β and IL−18 by 58.7% and 54.2%, respectively (Jiang et al. 2025).

The therapeutic effects of UTMD–mediated drug delivery are achieved through several mechanisms: 1) Promotion of angiogenesis: The ultrasound cavitation effect enhances HIF-1α/VEGF pathway activity, stimulating capillary formation in ischemic myocardium (Sun et al. 2022; Jiang et al. 2025). 2) Suppression of inflammatory responses: By delivering NLRP3 inhibitors, UTMD attenuates IL-1β and IL−18 release and reduces immune cell infiltration, thus alleviating inflammatory damage (Yang et al. 2022). 3) Enhancement of antioxidant capacity: UTMD–mediated delivery of nuclear factor erythroid 2-related factor 2 (Nrf2) agonizts activates the Keap1-Nrf2/ARE signaling pathway, increasing levels of endogenous antioxidants such as superoxide dismutase and glutathione, thereby reducing ROS–induced injury (Sun et al. 2022; Yang et al. 2022).

3.2. Three major advantages of UTMD in MIRI treatment

UTMD technology offers three significant advantages in the treatment of MIRI: (1) precise delivery of HIF-1α stabilizers (Lu et al. 2023), (2) targeted inhibition of the NLRP3 inflammasome, and (3) modulation of the myocardial microenvironment (Figure 4) (Lu et al. 2023). Representative UTMD strategies are summarized in Table S1.

Figure 4.

Three major therapeutic advantages of UTMD in MIRI, drawn by the authors (Created by BioRender).

3.2.1. Precise delivery of HIF-1α stabilizers

HIF-1α is a critical cellular transcription factor activated under hypoxic conditions and plays a pivotal role in myocardial repair by upregulating VEGF and promoting angiogenesis (Li et al. 2019; Zhang et al. 2024). However, following MIRI, oxidative stress accelerates HIF-1α degradation, leading to impaired VEGF signaling and insufficient vascular regeneration (Welt et al. 2024). UTMD enables the targeted delivery of HIF-1α stabilizers, such as DMOG and FG−4592, which inhibit prolyl hydroxylase–mediated degradation of HIF-1α, thereby enhancing VEGF expression and facilitating neovascularization and myocardial repair (Zhang et al. 2024; Chen et al. 2025). Animal studies have shown that UTMD–mediated delivery of HIF-1α stabilizers significantly increases myocardial microvascular density, reduces infarct size, and improves cardiac function (Welt et al. 2024, Chen et al. 2025).

The ‘no–reflow’ phenomenon following reperfusion represents a core pathological hallmark of MIRI, arising from a combination of endothelial swelling, microthrombus formation, and neutrophil–mediated capillary obstruction. UTMD restores microcirculatory perfusion through mechanisms involving hemodynamic optimization, regulation of the inflammation–thrombosis network, and suppression of oxidative stress. The oscillation of microbubbles reduces blood viscosity and enhances red blood cell deformability, leading to a marked improvement in capillary flow velocity within ischemic myocardial regions. Simultaneously, the cavitation effect increases the concentration of plasma nitric oxide metabolites (NOx), promoting microarteriolar dilation and improved tissue perfusion (Huang 2006). Moreover, the mechanical stimulation produced by UTMD facilitates endothelial release of tissue–type plasminogen activator (tPA), thereby enhancing fibrinolytic activity, while downregulating platelet P-selectin expression, which suppresses platelet aggregation. Preclinical studies have demonstrated that UTMD treatment significantly reduces microthrombus density in reperfused myocardial tissue (Zhou et al. 2022).

3.2.2. Targeted inhibition of the NLRP3 inflammasome

The NLRP3 inflammasome is a central mediator of inflammation during MIRI. Its overactivation leads to the release of IL-1β and IL−18, triggering pyroptosis and exacerbating myocardial injury (Majid 2024; Ha et al. 2024). UTMD enables the precise delivery of NLRP3 inhibitors such as MCC950 to the injured myocardium, effectively suppressing inflammasome activation and mitigating downstream inflammatory cascades (Cheng 2021; Xiang et al. 2024). Preclinical studies have confirmed that UTMD–mediated delivery of NLRP3 inhibitors markedly reduces myocardial inflammation, improves cardiac function, and alleviates secondary damage caused by MIRI (Liu et al. 2024; Chen et al. 2024).

3.2.3. Improvement of the myocardial microenvironment

MIRI is characterized by a detrimental myocardial microenvironment, driven by oxidative stress, inflammation, and apoptosis (Pan et al. 2024, Bu et al., 2024, Sun et al. 2025). Beyond delivering HIF-1α stabilizers and NLRP3 inhibitors, UTMD also facilitates the delivery of antioxidants, anti–inflammatory agents, and bioactive molecules (e.g. genes and proteins) to remodel the microenvironment (Pan et al. 2024, Chen et al. 2025). By scavenging excessive ROS, UTMD reduces oxidative stress–induced cardiomyocyte injury (Chen et al. 2025; Zhen et al. 2025). Moreover, UTMD enables the transport of anti–apoptotic factors, thereby inhibiting programmed cell death and promoting cardiomyocyte survival (Bu et al. 2024; Sun et al. 2025). Collectively, these effects contribute to a more favorable microenvironment for tissue regeneration, enhancing cardiomyocyte resilience and accelerating myocardial repair (Pan et al. 2024; Chen et al. 2025; Zhen et al. 2025).

The dynamic behavior of microbubbles within an ultrasonic field forms the core physical foundation of UTMD therapy. When exposed to ultrasound at specific resonance frequencies (typically 1–3 MHz), microbubbles undergo periodic expansion and contraction cycles, eventually collapsing and releasing energy–a process known as the acoustic cavitation effect. Depending on the intensity of energy release, cavitation can occur in two distinct modes: 1, Inertial cavitation, characterized by transient and violent bubble collapse, resulting in strong mechanical and thermal energy release. 2, Stable cavitation, involving sustained oscillations of microbubbles with milder energy output and more controllable biological effects. In the context of MIRI therapy, stable cavitation exerts protective, anti–injury effects through mechanisms involving mechanotransduction, mitochondrial protection, and inflammatory modulation. The oscillatory shear forces generated by microbubble vibration act on vascular endothelial cells, activating mechanosensitive ion channels such as Piezo1, which in turn stimulate the Akt–eNOS signaling pathway, enhancing nitric oxide (NO) synthesis. Experimental evidence shows that ultrasound exposure at 1 MHz and 0.5 W/cm² increases NO levels in ischemic myocardial regions by 2.3-fold (Cruz et al. 2016). Furthermore, the mild stress induced by cavitation initiates ischemic preconditioning–like protective responses, promoting the opening of mitochondrial ATP–sensitive potassium (mitoKATP) channels. This process mitigates calcium overload and inhibits mPTP opening during reperfusion. In animal models, activation of this pathway has been shown to reduce myocardial apoptosis by approximately 40% (Corretti et al. 2002).

In conclusion, UTMD technology demonstrates multiple therapeutic advantages in the treatment of MIRI by leveraging the synergistic effects of ultrasound cavitation and TMB delivery. It not only enables the precise administration of HIF-1α-related drugs to promote angiogenesis (Zhen et al. 2025), but also effectively inhibits NLRP3 inflammasome activation (Welt et al. 2024), thereby mitigating inflammation and protecting cardiomyocytes. With continuous advancements in ultrasound engineering and microbubble design, UTMD is poised to become an essential tool in cardiovascular precision medicine and an innovative solution for the targeted treatment of MIRI.

3.3. Recent applications of UTMD in MIRI treatment

UTMD, a non–invasive and highly targeted delivery technology, has evolved beyond a simple gene delivery tool into a multifunctional therapeutic platform capable of modulating various biological processes. Its core therapeutic advantage lies in the synergistic interplay between the mechanical forces generated by microbubble cavitation and the resulting biological responses, enabling precise intervention at ischemic sites.

UTMD–mediated gene delivery has demonstrated substantial benefits in promoting angiogenesis within ischemic myocardium. In particular, PHD2 gene silencing enhances the stability of HIF-1α, thereby activating downstream pro–angiogenic networks. Experimental studies in rat myocardial ischemia models have shown that UTMD–enhanced transfection significantly upregulates mRNA expression of VEGF, TGF-β, and basic fibroblast growth factor (bFGF). This leads to a marked increase in capillary density and restoration of increases markedly, and local blood flow to near–normal levels. Notably, cardiac functional parameters such as LVEF and left ventricular fractional shortening (LVFS) peaked at day 14 post–intervention, showing significant improvement compared to the control group (Zhou et al. 2022; Jiang et al. 2025).

Myocardial fibrosis, a key pathological hallmark of post–infarction remodeling, plays a critical role in the progressive decline of cardiac function. UTMD provides a promising strategy for anti–fibrotic therapy by enabling the targeted delivery of genetic modulators. In a pressure overload–induced HF model, UTMD–mediated transfection of microRNA-29b (miR-29b) mimics significantly inhibited the TGF-β/Smad3 signaling pathway, resulting in reduced collagen deposition and improved ventricular wall compliance. In another study, connective tissue growth factor (CTGF) siRNA delivered via cationic microbubbles targeted the focal adhesion kinase (FAK)-extracellular signal–regulated kinase 1/2 (ERK1/2) pathway in cardiac fibroblasts, leading to a reduction in myocardial fibrosis and a decrease in left ventricular end–diastolic pressure (Liu et al. 2015; Qin et al. 2018; Wu et al. 2023).

4. UTMD–mediated targeted regulation of the HIF-1α/VEGF signaling pathway

UTMD has demonstrated unique therapeutic advantages in MIRI, particularly in the regulation of the HIF-1α/VEGF signaling axis. By enabling the precise delivery of HIF-1α stabilizers that inhibit PHD2-mediated degradation, UTMD effectively promotes VEGF–mediated angiogenesis and accelerates myocardial tissue repair (Zhen et al. 2025).

4.1. Degradation mechanism of HIF-1α in the early stage of MIRI

HIF-1α serves as a central cellular mediator of hypoxic adaptation, inducing the expression of genes involved in angiogenesis, metabolism, and cell survival (Zhang et al. 2025). While hypoxia during the ischemic phase stabilizes HIF-1α, the reperfusion phase paradoxically accelerates its degradation due to increased oxidative stress.

Under normoxic conditions, PHDs catalyze the hydroxylation of specific proline residues on HIF-1α, facilitating its recognition by the von Hippel–Lindau (VHL) protein. The VHL–HIF-1α complex recruits an E3 ubiquitin ligase that targets HIF-1α for proteasomal degradation via the 26S proteasome (Figure 5) (Chen et al. 2024; Zhang et al. 2025). Among the PHD isoforms, PHD2 plays a predominant role in regulating HIF-1α stability. During hypoxia, PHD2 activity is inhibited, allowing HIF-1α to accumulate and initiate transcription of downstream target genes (Chen 2024; Zhang et al. 2025).

Figure 5.

UTMD–mediated regulation of the HIF-1α/VEGF signaling pathway, drawn by the authors (Created by BioRender). Note: (A) Degradation mechanism of HIF-1α during the early phase of MIRI; (B) Schematic illustration of UTMD–delivered HIF-1α stabilizers promoting myocardial repair.

To overcome the rapid degradation of HIF-1α during reperfusion, UTMD has been applied to deliver HIF-1α stabilizers such as dimethyloxalylglycine and FG−4592. These agents inhibit PHD activity, thus preventing HIF-1α hydroxylation and degradation (Figure 6) (Onasanya et al. 2025). Through ultrasound cavitation and TMB delivery, UTMD ensures localized and efficient drug deposition in ischemic myocardial regions, maintaining high drug concentrations precisely at the site of injury (Yue et al. 2024; Chen et al. 2024). Experimental data have demonstrated that UTMD–mediated delivery of HIF-1α stabilizers significantly upregulates myocardial HIF-1α protein levels, enhances VEGF expression, promotes capillary formation, and expedites myocardial repair (Zhen et al. 2025; Onasanya et al. 2025).

Figure 6.

Role of the HIF-1α/VEGF signaling pathway in myocardial repair, drawn by the authors (Created by BioRender).

4.2. VEGF–mediated angiogenesis

VEGF is a critical pro–angiogenic cytokine whose expression is transcriptionally regulated by HIF-1α (You et al. 2025). In the context of MIRI, therapeutic strategies aimed at increasing VEGF levels have shown promise in restoring microvascular integrity and enhancing myocardial perfusion (You et al. 2025). UTMD has been employed to deliver VEGF mRNA or VEGF–encapsulated nanoparticles directly to the ischemic myocardium, thereby boosting VEGF expression at the lesion site (You et al. 2025). Guided by ultrasound, TMBs selectively release VEGF cargo in reperfused myocardial regions, ensuring precise spatiotemporal control of angiogenic signaling (Zhigang et al. 2004; Shentu et al. 2018). Preclinical studies have confirmed that UTMD–mediated VEGF delivery significantly increases myocardial capillary density, reduces infarct size, and improves cardiac function (You et al. 2025).

Moreover, UTMD facilitates co–delivery of both HIF-1α stabilizers and VEGF mRNA, thereby achieving a dual–modality approach (Zhen et al. 2025; Onasanya et al. 2025). This strategy simultaneously inhibits HIF-1α degradation and boosts VEGF expression, resulting in improved neovascularization and myocardial tissue regeneration (Onasanya et al. 2025).

The vascular endothelium functions not only as a physical barrier between blood and tissues but also as a crucial endocrine and paracrine organ. Through shear stress–mediated endothelial remodeling, UTMD exerts protective effects in MIRI. The pulsatile shear forces generated by the cavitation effect activate the endothelial mechanosensory complex–comprising PECAM−1, VEGFR2, and VE–cadherin–which in turn triggers the PI3K–Akt signaling pathway, leading to phosphorylation of eNOS at Ser1177 and consequently enhancing the efficiency of NO synthesis. In a type II diabetes model, studies have demonstrated that low–intensity pulsed ultrasound significantly improves endothelium–dependent vasodilation (Xu et al. 2014). Notably, this endothelial modulation exhibits tissue specificity: in atherosclerotic plaque regions, the shear forces induced by UTMD can selectively induce apoptosis of dysfunctional endothelial cells while simultaneously promoting the repair of healthy endothelium, achieving a form of bidirectional regulation. This unique capability positions UTMD as a dual–function therapeutic modality–capable of targeted endothelial remodeling and vascular homeostasis restoration–thus offering distinct value in the treatment of atherosclerosis and other vascular pathologies.

The drug–free therapeutic effects of UTMD mark the advent of a new era in physical therapy for cardiovascular diseases. Through precisely regulated cavitation dynamics, microcirculatory reconstruction, and endothelial function modulation, UTMD demonstrates unique therapeutic potential in conditions such as myocardial ischemia–reperfusion injury, atherosclerosis, and diabetic cardiomyopathy. By leveraging biophysical mechanisms rather than relying on pharmacological agents, UTMD circumvents the metabolic limitations and off–target risks associated with conventional drug delivery. This innovative approach thus provides a novel paradigm for precision cardiovascular medicine, integrating mechanical bioregulation with targeted vascular restoration to achieve safer and more efficient clinical outcomes. In conclusion, UTMD offers a promising and highly targeted therapeutic platform for modulating the HIF-1α/VEGF axis in MIRI. By enabling precise delivery and achieving a 47% increase in microbubble targeting efficiency (Zhen et al. 2025), UTMD significantly enhances myocardial protection and functional recovery. These findings support the clinical potential of UTMD as a next–generation modality for precision cardiovascular therapy (Onasanya et al. 2025).

5. UTMD–Mediated targeted regulation of the NLRP3 inflammasome

Inflammatory responses induced by MIRI are a major contributor to cardiomyocyte death and cardiac dysfunction. Central to this process is the NLRP3 inflammasome (Liu et al. 2024), whose excessive activation promotes pyroptosis and the release of pro–inflammatory cytokines such as IL-1β and IL−18, thereby aggravating myocardial inflammation and tissue damage (Cheng 2021). Consequently, targeting the NLRP3 inflammasome has emerged as a promising therapeutic strategy for MIRI (Wang et al. 2025). In recent years, UTMD, as a precision drug delivery platform, has been extensively investigated for its ability to modulate NLRP3 activation, reduce inflammatory responses, and mitigate secondary myocardial injury (Onasanya et al. 2025).

5.1. Myocardial injury caused by excessive NLRP3 activation

The NLRP3 inflammasome is a critical regulator of the innate immune response. Following myocardial reperfusion, it becomes excessively activated by multiple stimuli, including oxidative stress, calcium overload, and mitochondrial dysfunction (Cheng 2021). Once activated, NLRP3 facilitates the cleavage of pro–caspase−1 into active caspase−1, which in turn processes pro–IL-1β and pro–IL−18 into their mature forms, amplifying the inflammatory cascade (Figure 7) (Liu et al. 2024). Furthermore, GSDMD generates the GSDMD-N fragment that forms membrane pores and induces pyroptosis–a form of inflammatory programmed cell death (Hu et al. 2022). Animal studies have confirmed that excessive NLRP3 activation increases cardiomyocyte death and significantly worsens post–MIRI cardiac dysfunction (Liu et al. 2024).

Figure 7.

Schematic diagram of UTMD–delivered NLRP3 inhibitor (MCC950) reducing inflammatory cytokine release, drawn by the authors (Created by BioRender).

To counteract these deleterious effects, several NLRP3 inhibitors have been developed, with MCC950 being one of the most well–characterized. MCC950 selectively inhibits NLRP3 assembly and activation, thereby reducing caspase−1 cleavage and suppressing IL-1β and IL−18 release (Li et al. 2023; Feng et al. 2025). Although MCC950 has shown potent anti–inflammatory and cardioprotective effects in preclinical models (Zheng et al. 2021), its clinical application is limited by poor targeting efficiency and the risk of systemic side effects (Li et al. 2023). Therefore, delivering MCC950 specifically to ischemic myocardial tissue has become a key focus to maximize therapeutic efficacy while minimizing off–target toxicity.

5.2. UTMD–mediated delivery of NLRP3 inhibitor (MCC950) reduces inflammatory cytokine levels

UTMD combines the physical effects of ultrasound cavitation with TMB technology to enable precise, site–specific drug release (Heun et al. 2017; Fan et al. 2022). In this context, MCC950 is encapsulated in or attached to TMBs and delivered to MIRI–affected regions. Upon ultrasound activation, microbubble rupture and the cavitation effect enhance vascular permeability, enabling localized delivery of MCC950 and improving its therapeutic efficacy (Ismailani et al. 2023). Preclinical studies have demonstrated that UTMD–mediated delivery of MCC950 significantly decreases the expression of IL-1β and IL−18, suppresses the inflammatory response, and attenuates myocardial injury (Ismailani et al. 2023).

Moreover, the targeting efficiency of UTMD can be further improved by functionalizing microbubbles with specific ligands such as RGD peptides, integrin αvβ3 antibodies, or other myocardial injury markers (Figure 8) (Feng et al. 2025). Recent studies show that UTMD–based delivery of MCC950 not only inhibits pyroptosis but also reduces infarct size, alleviates myocardial edema, and improves LVEF, highlighting its significant cardioprotective potential (Ishrat et al. 2021; Ma 2023).

Figure 8.

Schematic illustration of optimized UTMD design for enhanced targeted drug delivery, drawn by the authors (Created by BioRender).

Beyond MCC950, UTMD has also been employed to deliver alternative NLRP3 modulators such as miR−223 vectors and HIF-1α stabilizers (e.g. FG−4592), expanding its anti–inflammatory and pro–reparative capacity (Yang et al. 2024; Saller et al. 2025). The application of UTMD in these contexts not only enhances local drug accumulation but also facilitates combinatorial therapies, thereby improving overall treatment efficacy (Yang et al. 2024).

As a novel and precise drug delivery strategy, UTMD has shown clear advantages in the treatment of MIRI. By targeting and suppressing NLRP3 inflammasome activation, it effectively reduces cytokine release and inhibits pyroptosis, thus ameliorating inflammation and preserving cardiac function (Feng et al. 2025). Mechanistically, MCC950 binds to the Walker B motif of NLRP3 (Kd = 0.32 μM), inhibiting its ATPase activity and blocking ASC speck formation and caspase−1 activation (Ran et al. 2024). With continued refinement of UTMD techniques and microbubble design, this platform is poised to become a powerful therapeutic tool for MIRI and other inflammation–driven cardiovascular diseases (Zhang 2024).

6. Multi–omics analysis of UTMD in MIRI treatment

MIRI is characterized by complex pathophysiological processes, including energy metabolism dysregulation, oxidative stress, and inflammatory cascades. Single–cell multi–omics (scMulti–Omics) technologies offer high–resolution insights into the molecular profiles of distinct myocardial cell subpopulations (She et al. 2024). Recent studies have demonstrated that UTMD–mediated targeted nanodrug delivery (e.g. of the NLRP3 inhibitor MCC950) modulates lactylation in cardiac macrophages, thereby restoring the imbalance between glycolysis and mitochondrial oxidative metabolism (She et al. 2024). For example, scRNA–seq analysis revealed that UTMD–delivered miR−223 significantly inhibited the NLRP3/ASC/caspase−1 signaling cascade in CD68⁺ macrophages within ischemic regions, leading to a 62% reduction in IL-1β expression (She et al. 2024). Furthermore, integration of spatial metabolomics and lactyl–proteomics indicated that UTMD modulated lactylation at lysine 28 of malate dehydrogenase 2 (MDH2), enhancing mitochondrial complex I activity and reducing ROS production (She et al. 2024).

6.1. scRNA–seq

scRNA–seq allows comprehensive profiling of gene expression at the single–cell level, facilitating the identification of cellular heterogeneity and dynamic changes in myocardial tissue (Zhong et al. 2024). In the context of MIRI, scRNA–seq has been employed to assess transcriptomic alterations following UTMD intervention (Liu et al. 2024). Evidence suggests that UTMD–delivered drugs or gene vectors modulate myocardial gene expression, suppress inflammation (Liu et al. 2024; Chen et al. 2024), and promote cell survival and tissue regeneration (Wang 2023; Dong et al. 2024). For example, UTMD–mediated delivery of HIF-1α stabilizers was shown to upregulate angiogenesis–related genes in cardiomyocytes (Chen et al. 2024), enhance VEGF secretion, and promote myocardial neovascularization (Wang 2023; Jiang et al. 2024).

Moreover, scRNA–seq has been applied to evaluate the effects of UTMD on cardiomyocyte differentiation and reprogramming. UTMD–delivered specific factors have been shown to induce the differentiation of cardiac stem cells into mature cardiomyocytes, enhancing myocardial repair capacity (Chen et al. 2024). Through scRNA–seq, key regulatory genes such as HIF-1α, VEGF, and fibrosis–associated genes have been identified as dynamically modulated during UTMD–mediated cardiac repair (Li et al. 2023; Aghagolzadeh et al. 2023). For example, UTMD–based delivery of HIF-1α stabilizers was found to activate VEGF signaling, facilitating vascular regeneration in ischemic regions (Katoh et al. 2024).

However, technical limitations remain in scRNA–seq applications for MIRI, including challenges in isolating high–purity cardiomyocytes due to their large size and fragility, as well as high transcriptomic background noise (Shen et al. 2023, Li et al. 2023). Future research should focus on improving cell isolation techniques (e.g. microfluidic–based sorting) and adopting alternatives like single–nucleus RNA sequencing to enhance data reliability and reproducibility (Shen et al. 2023; Chen et al. 2024).

6.2. Proteomics

Proteomics enables comprehensive analysis of the entire protein landscape within cells, including protein abundance, structural characteristics, post–translational modifications, and interactions (Gao et al. 2019). In MIRI, proteomics has been utilized to elucidate the signaling pathways involved in the cardioprotective effects of UTMD (Lind et al. 2024). Studies have shown that UTMD–delivered therapeutic agents modulate the cardiomyocyte proteome, suppress apoptotic signaling, and enhance cell survival (Jia et al., 2025). For example, mass spectrometry–based analysis revealed that UTMD–mediated delivery of NLRP3 inhibitors decreased the expression of inflammation–associated proteins, leading to reductions in IL-1β and IL−18 release and attenuation of myocardial injury.

Proteomics also facilitates the evaluation of UTMD’s influence on cardiomyocyte metabolic pathways (Azimjonov et al. 2023; Du et al. 2024). UTMD–delivered factors have been shown to enhance mitochondrial energy metabolism and promote cellular repair processes (Du et al. 2024, Yang et al. 2024). Through proteomic profiling, key proteins upregulated or downregulated in response to UTMD have been identified, contributing to the understanding of the molecular basis of UTMD–driven myocardial recovery (Azimjonov et al. 2023; Du et al. 2024).

However, challenges persist in applying proteomics to MIRI, including difficulty in protein extraction from fibrotic myocardial tissue and the limited sensitivity in detecting low–abundance regulatory proteins, such as metabolic enzymes (Azimjonov et al. 2023). Future advancements should prioritize the development of improved extraction techniques and more sensitive quantification methods to enhance proteomic data quality (Du et al. 2024).

6.3. Metabolomics

Metabolomics involves the comprehensive analysis of small–molecule metabolites within cells, offering valuable insights into metabolic pathways and physiological alterations (Sun et al. 2023; Guo et al. 2024). In MIRI, significant metabolic dysregulation occurs, including disruptions in glycolysis, the tricarboxylic acid (TCA) cycle, and lipid metabolism. Metabolomics enables systematic identification of these perturbations, advancing the understanding of MIRI pathogenesis and facilitating the discovery of novel therapeutic targets (Cai et al. 2024; Chen et al. 2024). Recent studies have applied metabolomics to investigate how UTMD modulates mitochondrial metabolism in cardiomyocytes (Sun et al. 2023, Yang et al. 2024). UTMD–mediated delivery of therapeutic agents or gene vectors has been shown to regulate cardiomyocyte metabolic states and promote mitochondrial functional recovery (Yue et al. 2024; Wang et al. 2024). MIRI is characterized by increased glucose uptake and a metabolic shift toward glycolysis. Upregulation of HIF-1α enhances glucose transporter 1 expression, promotes lactate production, and elevates lactate dehydrogenase (LDH) activity. In contrast, mitochondrial pyruvate oxidation is impaired, accompanied by reduced levels of key TCA cycle intermediates such as citrate and succinate, indicating mitochondrial energy metabolism dysfunction (Xiang 2023; Kong et al. 2024). Moreover, during ischemia–reperfusion, the elevated release of free fatty acids (FFAs), activation of lipoxygenases, and increased ROS generation exacerbate oxidative stress–induced injury (Sun et al. 2023; Yue et al. 2024). Mass spectrometry–based analyzes have demonstrated that UTMD–mediated delivery of HIF-1α stabilizers enhances the levels of energy metabolism–related metabolites, improves mitochondrial function, and facilitates myocardial repair (Sun et al. 2023, Yang et al. 2024). Typical metabolic evaluations employ liquid chromatography–mass spectrometry to quantify metabolites such as ATP, lactate, and acetyl–CoA; gas chromatography–mass spectrometry to monitor TCA cycle intermediates including citrate, malate, and succinate; and nuclear magnetic resonance spectroscopy to comprehensively assess myocardial metabolic networks and global pathway activity (Yue et al. 2024; Guo et al. 2024).

Metabolomics also enables the evaluation of UTMD's effects on the redox status of cardiomyocytes (Figure 9) (Cai et al. 2024; Chen et al. 2024). By leveraging targeted delivery of drugs or genes via ultrasound microbubbles, UTMD precisely modulates key metabolic enzymes and restores impaired metabolic pathways (Yue et al. 2024). Specifically, UTMD–mediated delivery of HIF-1α stabilizers rebalances glycolysis and lactate metabolism, reduces the accumulation of metabolic byproducts, mitigates ROS production from FFA oxidation, alleviates oxidative stress, and stabilizes mitochondrial membrane potential–collectively promoting functional recovery of cardiomyocytes (Yang et al. 2024). Studies have confirmed that UTMD–delivered therapeutic agents effectively modulate cardiomyocyte redox balance, reduce oxidative stress, and protect myocardial tissue (Yue et al. 2024). Metabolomics facilitates the identification of key upregulated or downregulated metabolites following UTMD treatment, clarifying their roles in myocardial repair (Sun et al. 2023; Yang et al. 2024). In addition to identifying sensitive metabolic biomarkers, such as lactate, pyruvate, and FFAs, for early diagnosis and risk stratification of MIRI, metabolomics offers critical insights into the regulatory effects of UTMD on metabolic networks, thereby informing the optimization of clinical treatment strategies and improving therapeutic efficacy (Guo et al. 2024; Chen et al. 2024).

Figure 9.

Schematic diagram of UTMD combined with metabolomics for regulating cardiomyocyte metabolism, drawn by the authors (Created by BioRender).

However, challenges remain in the application of metabolomics to MIRI research, particularly in optimizing methodologies for metabolite quantification and identification (Saito et al. 2025). Future studies should focus on developing more robust and efficient strategies to enhance the accuracy and reproducibility of metabolomics data (Saito et al. 2025).

6.4. Integrated multi–omics analysis

The application of scMulti–Omics technologies enables simultaneous acquisition of genomic, transcriptomic, proteomic, and metabolomic data at the single–cell level, offering comprehensive insights into the mechanisms underlying UTMD–mediated treatment of MIRI (Baysoy et al. 2023; Luo et al. 2024). For example, the BD Rhapsody^TM system supports integrated analysis of transcriptomes, proteomes, and immunomes within the same cell, thereby accommodating diverse experimental requirements (Zhai and Xu 2021).

Through integrated multi–omics analysis, researchers can systematically evaluate the effects of UTMD on cardiomyocytes, elucidate its underlying molecular mechanisms, and provide a theoretical foundation for precision therapy in MIRI (She et al. 2024). For instance, the research team led by Tao Li and Liangming Liu at the Army Medical University combined metabolomics and proteomics to demonstrate that dexmedetomidine (Dex) inhibits lactylation of malate dehydrogenase 2 (MDH2), regulates metabolic reprogramming, and significantly reduces cardiomyocyte ferroptosis (She et al. 2024). This multi–omics approach revealed how UTMD–delivered therapeutics improve mitochondrial function via metabolic–immune interactions (She et al. 2024).

However, the integration and interpretation of multi–omics datasets require efficient computational frameworks and robust bioinformatics tools (She et al. 2024). For example, in analyzing scMulti–Omics data, algorithms such as MOFA⁺ are employed to correct batch effects, while spatial metabolomics techniques are used to localize region–specific metabolites in ischemic myocardial tissue (She et al. 2024). Future research should aim to optimize data processing and integration methods, such as the development of deep learning–based cross–omics network models, to enhance correlations across different omics layers and improve clinical translational potential (She et al. 2024).

By integrating genomic, transcriptomic, proteomic, and metabolomic data, a more comprehensive understanding of the therapeutic mechanisms of UTMD in MIRI can be achieved. For example, metabolomic analysis demonstrated that Dex reduced lactate levels; proteomic profiling confirmed the suppression of MDH2 lactylation; and transcriptomic analysis identified the NR3C1-PDK4 signaling axis as a regulator of the glycolytic pathway. This multi–dimensional integration provides a robust scientific basis for designing personalized treatment strategies (She et al. 2024).

Looking forward, the continuous advancement of scMulti–Omics technologies and the refinement of high–efficiency analytical tools are expected to make the integration of UTMD and multi–omics approaches a powerful strategy for MIRI therapy (She et al. 2024). By enabling precise drug delivery, targeted inhibition of inflammatory pathways, and restoration of metabolic homeostasis, this combination holds promise for delivering more accurate and individualized treatment options (She et al. 2024). Furthermore, the application of multi–omics in MIRI not only facilitates mechanistic elucidation but may also provide new therapeutic strategies for other cardiovascular diseases (She et al. 2024). For instance, integrated spatial metabolomics and proteomics have revealed a spatiotemporal correlation between lactate accumulation and macrophage infiltration in ischemic myocardial regions, thereby supporting the rationale for UTMD–mediated targeted delivery of LDH inhibitors (She et al. 2024).

7. Advantages and limitations of UTMD in MIRI

Traditional intravenous administration for MIRI treatment is limited by a pronounced first–pass effect and a low rate of drug accumulation at the lesion site (typically less than 5%). UTMD addresses this bottleneck through a triple–targeting mechanism. Focused ultrasound beams are directed at ischemic regions, triggering microbubble rupture only within the irradiated area and achieving spatially confined drug release via physical targeting. Ligands conjugated to the microbubble surface (such as anti–ICAM−1 antibodies or VEGF receptor–binding peptides) enable active binding to overexpressed molecules in ischemic tissue, enhancing retention through biological targeting. Additionally, the microjets and shear forces generated during microbubble collapse transiently widen endothelial gaps, promoting transvascular transport of macromolecules (such as DNA plasmids or antibodies) via cavitation–enhanced effects. This precise delivery mechanism is especially advantageous in gene therapy (Wu and Li 2017, Zhang et al. 2015). For example, in a canine myocardial infarction model, UTMD–mediated transfection of the angiopoietin−1 (Ang1) gene significantly increased Ang1 protein expression in the infarct border zone, promoted angiogenesis, and improved left ventricular synchrony, whereas systemic viral vectors posed a risk of hepatotoxicity (Deng et al. 2015).

As a novel non–invasive therapeutic modality, UTMD demonstrates remarkable potential in promoting myocardial repair through the synergistic effects of its mechanical and biological actions. The core principle lies in the cavitation effect triggered by ultrasound energy, which facilitates mechanical stimulation and targeted delivery, thereby directly modulating the myocardial microenvironment, promoting angiogenesis, inhibiting fibrosis, and improving cardiac function (Chen et al. 2013; Yang 2025).

The mechanical effects of UTMD originate from the local physical forces generated during microbubble cavitation, mainly involving the vigorous oscillation and collapse under ultrasound exposure. This process produces transient high–pressure shockwaves and microjets, which enhance cell membrane permeability and facilitate the targeted delivery of drugs or genes. In addition, the shear stress generated by cavitation can directly remodel the extracellular matrix (ECM) in myocardial tissue, while the transient opening of endothelial junctions induced by microbubble collapse allows reparative agents to penetrate the ischemic area (Chen et al. 2013; Endo-Takahashi and Negishi 2020).

Beyond its role as a delivery platform, UTMD also exerts biological effects that actively regulate myocardial repair. Recent studies have demonstrated that UTMD can recruit M2-type macrophages. In experiments combining multifunctional pericardial devices (PerMed) with UTMD, the number of M2 macrophages in infarct zones increased more than twofold, promoting an anti–inflammatory microenvironment and accelerating wound healing (Xiang et al. 2018; Huang et al. 2021).

However, the application of UTMD in MIRI still faces challenges. Its therapeutic efficacy is highly dependent on the precise tuning of ultrasound parameters and microbubble characteristics. Excessive ultrasound intensity may cause capillary rupture, whereas insufficient intensity may lead to incomplete drug release. Moreover, ultrasound waves are significantly attenuated when passing through bone or lung tissue, limiting penetration depth and reducing targeting efficiency for posterior myocardial regions. Additionally, myocardial fibrosis and local perfusion conditions may influence microbubble distribution (Han et al. 2022; Liu et al. 2022).

With its high targeting precision, ability to improve microcirculation, and spatiotemporal controllability, UTMD represents a highly promising technology for MIRI treatment. Nevertheless, challenges such as standardization of treatment parameters, drug–loading stability, and clinical translation must be addressed to fully harness its therapeutic potential.

8. Future perspectives

Despite the considerable therapeutic promise of UTMD in treating MIRI, several challenges must be addressed before its clinical application can be realized. First, the long–term safety and biocompatibility of UTMD–based delivery systems require further investigation. The ultrasound–induced cavitation effect may cause localized tissue damage, and the degradation products of microbubbles and nanocarriers could potentially trigger immune or toxic responses. Thus, a comprehensive evaluation of the long–term biosafety and compatibility of UTMD platforms is essential.

The rapid development of nanomedicine has opened new avenues for optimizing UTMD in the context of MIRI. Microbubble–nanoparticle hybrid systems have emerged as a promising strategy for enhancing UTMD–mediated drug delivery (Jiang et al. 2025). For instance, UTMD can incorporate redox–responsive nanoparticles, such as ROS–triggered carriers, to release antioxidant drugs selectively in ischemic regions (Zhen et al. 2025). Furthermore, smart biocompatible materials, including cell membrane–coated nanoparticles, offer improved microbubble stability, prolonged circulation time, and enhanced targeting efficiency (Jiang et al. 2025). In the future, combining UTMD with advances in biomaterials–such as adaptive nanogels or extracellular vesicle–modified microbubbles–may further expand its therapeutic potential in MIRI.

As UTMD evolves, it is expected to integrate more deeply with precision medicine, propelling the development of personalized cardiovascular therapies. With advances in scRNA–seq, spatial omics, and AI–driven data analysis, UTMD delivery strategies could be tailored to individual patient profiles, including genetic background, metabolic status, and microcirculatory characteristics (Jiang et al. 2025). For example, AI algorithms can be used to analyze myocardial radiomics data, predict MIRI progression, and guide real–time adjustments to UTMD parameters to enhance treatment precision (Wang et al. 2025). Looking ahead, the combination of UTMD with multi–omics analysis may facilitate the identification of MIRI subtype–specific mechanisms and support the development of individualized therapeutic strategies, advancing the frontiers of cardiovascular precision medicine.

In addition, the integration of UTMD with CRISPR/Cas9 gene–editing technology presents a novel and highly promising approach for the treatment of cardiovascular diseases. Current studies have shown that CRISPR/Cas9 can correct pathogenic gene mutations related to MIRI (e.g. NOS3, HIF1A, TNF); however, traditional viral vectors pose limitations due to immunogenicity and off–target effects (Jiang et al. 2025). UTMD offers a non–viral delivery alternative, enabling ultrasound–guided, site–specific transfection of sgRNA and Cas9 into cardiomyocytes for precise gene editing (Zhen et al. 2025). Moreover, next–generation gene–editing tools, such as CRISPR/Cas13d for RNA editing and base editors, when combined with UTMD, may help avoid double–stranded DNA breaks and reduce genomic instability, improving gene therapy safety (Jiang et al. 2025). In the future, integrating UTMD with AI–powered predictive models could further optimize target site selection for gene editing, paving the way for personalized genetic interventions in MIRI.

In recent years, mRNA therapy has emerged as a powerful modality for cardiovascular disease treatment, and UTMD has been shown to significantly improve the delivery efficiency and stability of mRNA in myocardial tissue (Wang et al. 2025). For example, UTMD–mediated VEGF mRNA delivery increased myocardial microvascular density by 3.5 ± 0.7-fold and reduced fibrosis in ischemic regions (Jiang et al. 2025). In addition, mRNA–based therapies targeting MIRI–related signaling pathways–such as HIF-1α mRNA for promoting angiogenesis or IL−10 mRNA for attenuating inflammation–have shown promising results when delivered via UTMD (Zhen et al. 2025). Future developments in mRNA platforms, including circular RNA and self–amplifying RNA, when combined with the targeted capabilities of UTMD, may enable more durable and efficient strategies for myocardial repair. Furthermore, the integration of UTMD with AI–enhanced imaging technologies could provide real–time assessment of myocardial perfusion and predictive modeling of MIRI progression, thereby optimizing clinical decision–making.

In summary, UTMD represents a cutting–edge drug delivery system with significant potential for integration with gene editing, mRNA therapeutics, and AI–guided imaging. While its clinical translation still faces challenges–including safety validation, parameter optimization, and ethical considerations–future research should prioritize overcoming these barriers to fully realize the promise of UTMD in precision medicine. This approach offers novel insights and transformative strategies for the treatment of MIRI.

9. Conclusion

The particular suitability of UTMD for MIRI arises from the close alignment between its unique technical features and the complex pathophysiology of MIRI. This suitability is reflected not only in its ability to overcome the limitations of conventional therapies, but also in the precise temporal matching between its physical–biological effects and the dynamic therapeutic window of MIRI.

First, the very nature of MIRI determines the limitations of conventional therapies, thereby highlighting the necessity of UTMD. PCI can successfully reopen the occluded epicardial arteries but fails to address key subsequent issues such as microvascular dysfunction (the ‘no–reflow’ phenomenon), explosive inflammatory reactions, and intracellular calcium overload. Traditional systemic drug administration is also limited by poor myocardial targeting, low effective concentrations, and systemic side effects. MIRI represents a dynamic pathological process that occurs within a specific temporal window (initiated at the onset of reperfusion and continuing thereafter) and a specific spatial domain (the ischemic microenvironment). Therefore, an effective therapeutic strategy must possess precise spatiotemporal targeting capabilities. UTMD fills this gap perfectly: by using microbubbles as both carriers and amplifiers, it enables the efficient and controllable delivery of therapeutic agents (such as genes, drugs, and proteins) directly to the ischemic myocardium under the precise guidance of ultrasound–achieving a transition from ‘vascular reopening’ to ‘tissue rescue.’ More importantly, the biophysical effects of UTMD are highly consistent with the pathophysiological windows of MIRI in both timing and mechanism, forming its core advantage. At the moment of reperfusion, explosive oxidative stress and calcium overload cause endothelial swelling and glycocalyx shedding, leading to microvascular obstruction. At this stage, the cavitation effect of UTMD generates microstreaming and shear forces that physically ‘clear’ capillaries blocked by cell debris and leukocytes, immediately improving microcirculatory perfusion. At the same time, moderate mechanical stimulation activates the eNOS/NO signaling pathway, counteracting vasospasm, promoting vasodilation, and creating favorable conditions for subsequent pharmacological intervention. In the early reperfusion phase (a few hours to 24 h), the inflammatory storm becomes dominant. The NLRP3 inflammasome is activated, driving the release of pro–inflammatory cytokines such as IL-1β and initiating pyroptotic cell death. UTMD at this stage exerts its mechanical immunomodulatory effects: the mechanical signals from cavitation can directly inhibit NLRP3 assembly and modulate integrin–related signaling pathways, promoting the polarization of macrophages from the pro–inflammatory M1 phenotype to the reparative M2 phenotype, thereby mitigating inflammation at its source. Through targeted delivery of inhibitors such as MCC950, UTMD can further ‘brake’ the inflammatory cascade with high precision. In the late reperfusion phase (24–72 h and beyond), cell survival–death decisions and tissue repair become the main focus. Persistent opening of the mPTP leads to apoptosis and necrosis, while fibrotic remodeling begins. At this stage, UTMD acts as a spatiotemporal express system for gene and drug delivery–transporting cyclosporine A analogs to inhibit mPTP opening, or VEGF genes to promote angiogenesis–thus directly influencing cell fate and initiating repair. Crucially, the mechanical stimulation generated by UTMD itself can serve as a pro–survival signal, inducing mitophagy, removing damaged organelles, and enhancing the stress tolerance of cardiomyocytes.

In summary, the particular suitability of UTMD for MIRI lies in its ability to provide a synergistic strategy that combines physical intervention with biological regulation. It not only resolves the challenge of spatially precise drug targeting, but also, through its multifunctional physical–biological effects, achieves temporal coordination with the evolving pathophysiological stages of MIRI–from microvascular obstruction, inflammatory storm, and cell death to tissue repair. Thus, UTMD enables a level of precise management and active repair throughout the entire reperfusion process that is difficult to achieve with conventional therapeutic methods (Figure 10).

Figure 10.

Schematic illustration of the spatiotemporal mechanisms through which UTMD modulates distinct pathological stages of MIRI (Created by BioRender).

With the ongoing advancement of radiomics and AI technologies, the therapeutic efficacy of UTMD has been further improved. Radiomics facilitates the quantitative analysis of multimodal imaging data, and when combined with deep learning algorithms, enables accurate prediction of MIRI progression–laying the groundwork for personalized treatment strategies. The integration of AI technologies also supports real–time monitoring of myocardial perfusion during UTMD–based therapy, allowing dynamic adjustment of treatment protocols and paving the way for precision medicine.

This review summarizes recent progress in UTMD for MIRI therapy, detailing its mechanisms in regulating the HIF-1α/VEGF signaling axis and NLRP3-mediated immune responses, while also highlighting the latest research integrating radiomics and AI to optimize UTMD applications. These insights provide valuable reference points for the clinical translation of UTMD in MIRI. Nevertheless, further clinical validation and technological refinement are needed to address current limitations and facilitate the broader application of UTMD in the era of precision cardiovascular medicine.

Supplementary Material

Supplementary Material

Table S1. Summary of Common UTMD-Based Therapeutic Strategies.

Supplemental Material

Supplemental data for this article can be accessed at https://doi.org/10.1080/10717544.2025.2594555.

Acknowledgements

None.

Author contributions

CRediT: Wei Feng: Conceptualization, Investigation, Methodology, Visualization, Writing – original draft; Pingping He: Data curation, Investigation, Methodology, Validation, Writing – review & editing; Zhimin Wang: Conceptualization, Project administration, Resources, Supervision, Visualization, Writing – review & editing; Weishuai Li: Conceptualization, Project administration, Resources, Supervision, Validation, Writing – review & editing.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Funding

None.

Data availability statement

This article is a review, and no new experimental data were generated. All data and analyzes presented are derived from published literature cited in the references. Additional inquiries can be directed to the corresponding authors, Zhimin Wang (hiamywang@163.com) or Weishuai Li (wsli@cmu.edu.cn).

Ethical statement

No need.