Cardiac Path Online

The International Society for Heart and Lung Transplantation (ISHLT) System for Grading Rejection:





Revised Grading:(2004)

ISHLT - 2004  Acute  Rejection Grading:



 Histopathology findings
0 R, None


1 R, Mild


Interstital and/or perivascular infiltrate with up to one focus of myocyte damage.


2 R, Moderate Two or more foci of  infiltrate with associated myocyte damage


3 R, Severe Diffuse infiltrate with multifocal myocyte damage +/- edema +/- hemorrhage +/- vasculitis

ISHLT Finalizes New Nomenclature and Diagnostic Criteria

The revised ISHLT heart biopsy grading scale


Old term               Grades Notes Proposed simplification (1994)
No rejection             0  

Biopsies with very sparse lymphoid infiltrates should be included in this grade.


Mild rejection            1A  

Focal perivascular or interstitial infiltrates.

The mild intensity and lack of myocyte damage distinguish this from higher grades.


 Grade 1
Mild rejection  1B   

Diffuse but sparse infiltrate. As with 1A, there must be no myocyte damage.


 Grade 1
‘Focal’ moderate rejection         2  

One focus only with  aggressive infiltration and/or focal myocyte damage.

The choice of a single focus as the cut-off from higher grades is arbitrary in practice, with the amount of tissue usually submitted, one is unlikely to be faced with the problem of biopsy fragments with only two foci


  Grade 1


                                     Usual treatment threshold



‘Low’ mod rejection     3A  

Multifocal aggressive infiltrates and/or  myocyte damage.

The multiple foci may be present in only one fragment or may be scattered through out several fragments.   


 Grade 3A
‘Low’ mod rejection    3B  

Diffuse inflammatory  process .The   intensity of the lymphoid infiltrate     varies considerably.

It may be little more than grade 1B, the important distinguishing feature being the presence of myocyte damage.

This damage must be present in at least two fragments, but some degree of infiltration is present in the majority of fragments.


 Grade 3B
"Severe" acute  rejection             4  

A diffuse and polymorphous infiltrate with or without oedema,         haemorrhage and vasculitis.

The infiltrate is  more intense and more widespread than 3B and myocyte is conspicuous.

There are often neutrophils and/or haemorrhage, though neither is essential for diagnosis of this grade. 


  Grade 4

Related post:   

Heart transplant - Pathological Examination

Reporting of endomyocardial biopsy (Allograft rejection)


Further reading:

Acute Cellular Rejection Tutorial

Has the 2004 revision of the International Society of Heart and Lung Transplantation grading system improved the reproducibility of the diagnosis and grading of cardiac transplant rejection?

Nodular endocardial infiltrates (Quilty lesions) cause significant variability in diagnosis of ISHLT Grade 2 and 3A rejection in cardiac allograft recipients.

Effect of adopting a new histological grading system of acute rejection after heart transplantation.

A revision of the 1990 working formulation for the classification of lung allograft rejection.

Acute rejection: significance of lapsed time post transplant.

A classification of cardiac allograft rejection. A modification of the classification by Billingham.





Dr Sampurna Roy  MD

Consultant  Histopathologist (Kolkata - India)







Infectious Disease Online


Pathology Quiz Online 


Paediatric Pathology Online


Pancreatic Pathology Online




Endocrine Pathology Online


Eye Pathology Online


Ear Pathology Online


Cardiac Path Online


Pulmonary Pathology Online


Lung Tumour Online




Nutritional Pathology Online


Environmental Pathology Online


Soft Tissue Tumour Online


GI Path Online-India


Gallbladder Pathology Online


E-book - History of Medicine  


Microscope - Seeing the Unseen



Privacy Policy  

Advertising Policy

Copyright © 2018