This study was designed to assess the effects of simultaneous antegrade/retrograde cardioplegia (SARC) on myocardial perfusion and energy metabolism in the region supported by the occluded left anterior descending artery (LAD) in isolated pig hearts. It was found that injection of Gd-DTPA into the aorta during antegrade cardioplegia (AC) did not result in signal increase in the LAD region on T(1)-weighted images. During SARC, however, Gd-DTPA was detected in the LAD region with the contrast agent injected into the aorta and the coronary sinus (CS), respectively. This suggests that SARC delivered blood cardioplegia to the jeopardized myocardium through both arterial and venous perfusion routes. Moreover, localized (31)P spectra showed that occlusion of the LAD during AC resulted in severe ischemic changes in the LAD myocardium and the abnormal metabolic changes were completely abolished by use of SARC. Finally, recovery of myocardial contractile function during reperfusion in the hearts subjected to SARC was significantly better compared to those arrested with AC alone. It was concluded that the myocardium distal to a coronary occlusion can be fully protected by use of SARC.