Sanada S, Komuro I, Kitakaze M. Pathophysiology of myocardial reperfusion injury: preconditioning, postconditioning, and translational aspects of protective measures. Am J Physiol Heart Circ Physiol 301: H1723-H1741, 2011. First published August 19, 2011; doi:10.1152/ajpheart.00553.2011.-Heart diseases due to myocardial ischemia, such as myocardial infarction or ischemic heart failure, are major causes of death in developed countries, and their number is unfortunately still growing. Preliminary exploration into the pathophysiology of ischemia-reperfusion injury, together with the accumulation of clinical evidence, led to the discovery of ischemic preconditioning, which has been the main hypothesis for over three decades for how ischemia-reperfusion injury can be attenuated. The subcellular pathophysiological mechanism of ischemia-reperfusion injury and preconditioninginduced cardioprotection is not well understood, but extensive research into components, including autacoids, ion channels, receptors, subcellular signaling cascades, and mitochondrial modulators, as well as strategies for modulating these components, has made evolutional progress. Owing to the accumulation of both basic and clinical evidence, the idea of ischemic postconditioning with a cardioprotective potential has been discovered and established, making it possible to apply this knowledge in the clinical setting after ischemia-reperfusion insult. Another a great outcome has been the launch of translational studies that apply basic findings for manipulating ischemia-reperfusion injury into practical clinical treatments against ischemic heart diseases. In this review, we discuss the current findings regarding the fundamental pathophysiological mechanisms of ischemiareperfusion injury, the associated protective mechanisms of ischemic pre-and postconditioning, and the potential seeds for molecular, pharmacological, or mechanical treatments against ischemia-reperfusion injury, as well as subsequent adverse outcomes by modulation of subcellular signaling mechanisms (especially mitochondrial function). We also review emerging translational clinical trials and the subsistent clinical comorbidities that need to be overcome to make these trials applicable in clinical medicine. calcium overload; reactive oxygen species; mitochondria; transition pore; comorbidities; clinical trials WHAT DO WE KNOW ABOUT ischemia-reperfusion injury? Because the morbidity and mortality due to ischemic heart diseases have come to the fore in developed countries and are still increasing, it is critically important, both scientifically and socially, to know how cardioprotection is achieved in ischemic myocardium. In fact, in the clinical setting, the application of coronary thrombolysis or immediate percutaneous coronary intervention for faster recanalization has been shown to dramatically improve the outcomes of patients with acute or chronic myocardial ischemia due to impaired coronary blood supply. This finding is founded on the premise that a shorter period of index ischemia...