The regenerative and reparative potential of mesenchymal stem cells (MSCs) make them attractive candidates for numerous cell-directed therapies. The variant degree of tissue repair by transplanted MSCs has been assessed in several published reports. There are many gaps in the knowledge of MSC biology and the underlying reasons for their disparate effectiveness in tissue repair. This review examines successful preclinical models of MSC-directed repair, particularly of myocardial repair, in an attempt to shed light into the events dictating MSC therapeutic efficacy. The reparative advantage of genetically altered MSCs will be described. This overview will elucidate possible molecular mechanisms that can influence MSC engraftment, differentiation, self-renewal, and ultimately increase wound repair.