The International Society for Heart and Lung Transplantation (ISHLT) has developed a grading system for cardiac transplant rejection based on the histologic examination of a heart biopsy.
no acute rejection
focal, mild acute rejection
diffuse, mild acute rejection
focal, moderate acute rejection
multifocal moderate rejection
diffuse, borderline severe acute rejection
severe acute rejection
Inflammatory Cell Infiltrate
Myocyte Damage and Other Findings
focal perivascular or focal interstitial infiltrate of large, reactive lymphocytes
diffuse but sparse interstitial infiltrate of large, reactive lymphocytes
one focus of aggressive lymphocytic infiltrate, AND/OR
AND/OR, single focus of myocyte damage
multifocal aggressive infiltrates of large, reactive lymphocytes, AND/OR
AND/OR multifocal myocyte damage
diffuse lymphocytic infiltrate with either eosinophils or granulocytes
multifocal myocyte damage, with necrosis
diffuse, aggressive inflammatory cell infiltrate with large, reactive lymphocytes, eosinophils and neutrophils
extensive myocyte damage with necrosis; often with edema, hemorrhage and/or vasculitis
• It may be difficult to identify myocyte damage.
• It does not take into account the number of biopsy fragments showing evidence of rejection.
• Grade 2 rejection may be mimicked by a variety of phenomenon.
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Specialty: Cardiology, Surgery, general