Cellular therapy for cardiovascular disease heralds an exciting frontier of research. Mesenchymal stromal cells (MSCs) are present in adult tissues, including bone marrow and adipose, from which they can be easily isolated and cultured ex vivo. Although traditional isolation of these cells by plastic adherence results in a heterogeneous composite of mature and immature cell types, MSCs do possess plasticity of differentiation and under appropriate in vitro culture conditions can be modified to adopt cardiomyocyte and vascular cell phenotypic characteristics. In vivo preclinical studies have demonstrated their capacity to facilitate both myocardial repair and neovascularization in models of cardiac injury. The mechanisms underlying these effects appear to be mediated predominantly through indirect paracrine actions, rather than direct regeneration of endogenous cells by transdifferentiation, especially because current transplantation strategies achieve only modest engraftment of cells in the host myocardium. Currently, published clinical trial experience of MSCs as cardiac therapy is limited, and the outcomes of ongoing studies are keenly anticipated. Of relevance to clinical application is the fact that MSCs are relatively immunoprivileged, potentially enabling their allogeneic therapeutic use, although this too requires further investigation. Overall, MSCs are an attractive adult-derived cell population for cardiovascular repair; however, research is still required at both basic and clinical levels to resolve critical areas of uncertainty and to ensure continued development in cell culture engineering and cell transplantation technology.