There are two mechanical determinants of coronary blood flow and its distribution: resistance and pressure gradient. Resistance is determined by blood viscosity and the anatomy and geometry of the coronary vascular bed. The coronary vascular pressure gradient is the difference between aortic root pressure and intramyocardial pressure. A number of factors such as coronary atherosclerosis, ventricular hypertrophy, and myocardial edema may adversely affect the determinants of coronary flow before, during, or after cardiopulmonary bypass, thereby lowering or eliminating regional or local coronary reserve and promoting the likelihood of a myocardial ischemic injury. The subendocardial layers of the left ventricle appear to be more vulnerable, perhaps in part because they depend entirely on diastolic coronary flow.