Apoptosis is associated with acute rejection, transplant vascular disease, and the "Quilty effect" in cardiac allografts. However, the causality and mechanisms of apoptosis in the pathogenesis of vascular injury are poorly understood. In the current study, the Lewis-to-F344 rat cardiac allograft model was utilized as a means to immunohistochemically evaluate the expression of Bax, Bcl-2, and factor VIII-related antigen in transplant vascular disease. Apoptosis was detected by in situ labeling of fragmented DNA using in situ terminal deoxyribonucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) in native hearts and grafted hearts of allogeneic and syngeneic recipients. Bax immunostaining was detected in 50% of endothelial cells, in 60% of infiltrating leukocytes associated with acute rejection in the myocardium, and in certain other parenchymal cells, considering all cardiac allografts. More than 75% of infiltrating leukocytes in the intima of vessel walls immunostained positive for Bax. Bcl-2 immunopositivity was not detected in native hearts, allo allo-, or syngrafts. On Days 2, 4, 7, and 14 after transplantation, TUNEL positivity was detected in only about 1% of leukocytes in the interstitial infiltrates, despite the fact that rather severe rejection was observed in Day 14 allografts. The number of apoptotic leukocytes increased significantly by Days 28 and 56 after transplantation, although the severity of histopathological rejection did not increase as compared with Day 14. The apoptotic leukocytes remained isolated or in small clusters, mainly perivascular. TUNEL positivity colocalized with Bax expression in these cells. TUNEL staining was also observed in certain parenchymal cells in the interstitium and in randomly distributed inflammatory cells in vessel walls. TUNEL positivity was detected in rare luminal endothelial cells in transverse sections of vessel walls (about 10% of cells in <1/10 of the vessels studied). Nuclear TUNEL positivity was observed in Bax-negative cardiomyocytes in ischemically damaged areas of myocardium in both allografts and syngrafts. In summary, increased expression of Bax was observed in rat cardiac allografts. The colocalization of TUNEL and Bax suggests that endothelial cell injury and infiltrating leukocyte apoptosis may be regulated in part by the apoptosis-promoting protein, Bax. In the current model, myocyte death due to ischemia and surgical injury in syngrafts and allografts does not seem to involve Bax.