Possible mechanisms involved in the development of the calcium paradox

Reperfusion of an isolated heart with calcium-containing solution after a short period of calcium-free perfusion may result in excessive influx of calcium into the cells and irreversible cell damage (calcium paradox). This paper describes the possible routes of calcium entry that occurs during the phase of calcium repletion, and the possible mechanisms involved in the development of the calcium paradox damage. The routes of calcium entry include the glycocalyx, the slow channels, the Na+-Ca2+ exchange mechanism, passive diffusion, and abnormal sites of calcium entry. In addition to an increased influx of calcium, a loss in the ability of the sarcolemma to remove calcium from the cells may contribute to the net gain of tissue calcium. The calcium paradox damage itself, which follows the massive influx of calcium into the myocardial cells, may be a result of calcium-triggered energy dependent reactions and a concomitant acidification of the cytoplasm. Mechanical factors may also be involved in the development of the calcium paradox.