Cardiac lymphatics: functional plasticity in development, disease, and precision-targeted therapies

The cardiac lymphatic system plays a crucial role in maintaining myocardial homeostasis by regulating fluid equilibrium, immune surveillance, and metabolite clearance. This review highlights recent advances in understanding its development, molecular regulation, dual roles in pathophysiology, and translational potential. Cardiac lymphatic endothelial cells (LECs) develop from diverse progenitors, including venous endothelium and Isl1⁺ precursors from the second heart field (SHF) under sex-specific molecular guidance. Functionally, the Vascular endothelial growth factor C (VEGFC)/Vascular endothelial growth factor receptor 3 (VEGFR3) signaling is paramount, modulated contextually by factors like adrenomedullin and branched-chain ketoacid dehydrogenase kinase (BCKDK). Lymphatic dysfunction impacts cardiovascular disease paradoxically. While protective in the acute phase of myocardial infarction by limiting inflammatory edema, it becomes detrimental in chronic hypertension and calcific aortic valve disease (CAVD). Single-cell transcriptomics (scRNA-seq) resolve this contradiction by revealing distinct functional LEC subpopulations: Transforming growth factor-beta 1 (TGF-β1)⁺/Interleukin 10 (IL-10)⁺ LECs promote post-infarction repair, while Reelin⁺/C-C motif chemokine ligand 21 (CCL21)⁺ LECs promote osteogenesis and valve calcification in CAVD. Emerging strategies focus on cardiac-targeted nanotherapeutics, epigenetic and metabolic LEC modulation, and sex-specific dosing. Critical unresolved questions involve autonomic nerve-lymphatic integration and lineage-specific epigenetic memory. Advancing precision lymphatic imaging, genotype-informed clinical trials, and spatiotemporal control of LEC phenotypes is critical for therapeutic translation. Deeper understanding promises novel treatments for heart failure, inflammatory cardiomyopathies, and fibrosis.