Cardiac xenotransplantation (cXT) has emerged as a solution to heart donor
scarcity, prompting an exploration of its scientific, ethical, and regulatory
facets. The review begins with genetic modifications enhancing pig hearts for
human transplantation, navigating through immunological challenges, rejection
mechanisms, and immune responses. Key areas include preclinical milestones,
complement cascade roles, and genetic engineering to address hyperacute
rejection. Physiological counterbalance systems, like human thrombomodulin and
endothelial protein C receptor upregulation in porcine xenografts, highlight
efforts for graft survival enhancement. Evaluating pig and baboon donors and
challenges with non-human primates illuminates complexities in donor species
selection. Ethical considerations, encompassing animal rights, welfare, and
zoonotic disease risks, are critically examined in the cXT context. The review
delves into immune control mechanisms with aggressive immunosuppression and
clustered regularly interspaced palindromic repeats associated protein 9 (CRISPR/Cas9) technology, elucidating hyperacute rejection, complement activation,
and antibody-mediated rejection intricacies. CRISPR/Cas9’s role in creating pig
endothelial cells expressing human inhibitor molecules is explored for rejection
mitigation. Ethical and regulatory aspects emphasize the role of committees and
international guidelines. A forward-looking perspective envisions precision
medical genetics, artificial intelligence, and individualized heart cultivation
within pigs as transformative elements in cXT’s future is also explored. This
comprehensive analysis offers insights for researchers, clinicians, and
policymakers, addressing the current state, and future prospects of cXT.