Accumulation of sodium-ions (Na+) in myocardial cells during both ischemia and calcium (Ca2+)-free perfusion has been suggested to play an important role in the damage occurring during subsequent reperfusion and calcium repletion, respectively. We have used 23Na NMR spectroscopy in combination with shift reagents to determine intracellular Na(+)-concentration [( Na+]i) in isolated rat hearts during either control perfusion followed by ischemia and reperfusion, or during control perfusion, Ca(2+)-free perfusion and subsequent ischemia. [Na+]i during control perfusion was found to be 10.5 +/- 0.6 mmol/l. During 30 min of ischemia [Na+]i rose substantially to 25.0 +/- 3.2 mmol/l. During 15 min of reperfusion [Na+]i initially decreased, but leveled off after approximately 3 min and was 17.9 +/- 3.7 mmol/l at the end of the reperfusion period. Most surprisingly, however, no significant increase of [Na+]i was observed during 30 min of Ca(2+)-free perfusion, although severe calcium paradox damage was shown to occur under the used conditions, when calcium was readmitted to the heart. The absence of a rise of [Na+]i during Ca(2+)-free perfusion was substantiated when during subsequent ischemia a similar rise of [Na+]i was observed as during ischemia without previous Ca(2+)-depletion. We conclude that an increased [Na+]i during Ca(2+)-depletion is not a prerequisite for the calcium paradox to occur, but that increased [Na+]i during ischemia may influence the subsequent reperfusion damage through Na(+)-Ca2+ exchange.