General (transplant)

Topic Completed: 1 December 2015

Minor changes: 26 September 2019

Copyright:2015-2019, PathologyOutlines.com, Inc.

PubMed Search: Heart [title] transplant [title] (Review[ptyp] "loattrfree full text"[sb])

R. Amita, M.D.
Page views in 2020: 1,659
Page views in 2021 to date: 48
Cite this page: Amita R. General (transplant). PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/hearttransplant.html. Accessed January 18th, 2021.
Definition / general
  • First human heart transplantation was performed in 1967 (S Afr Med J 2011;101:97)
  • Heart transplantation remains the most effective therapy for end stage heart disease of coronary and noncoronary etiology
  • More than 73,000 heart transplants have been performed worldwide to date
  • Donor heart dysfunction results from the "catecholamine storm" (hypertension, tachycardia and intense vasoconstriction) that produces an increase in myocardial oxygen demand and potential myocardial ischemia
  • These phenomena may mediate myofibrillar degeneration, a process characterized by injury and death of myofibers in a hypercontracted state
  • After dissipation of this intense sympathetic activity, there is loss of sympathetic tone with a massive reduction in systemic vascular resistance, which may contribute to a second phase of potential myocardial injury, precipitated by abnormal myocardial loading conditions and impaired coronary perfusion
  • Myocardial injury interacts with other factors such as older donor age and longer ischemic time, increasing the probability of postoperative primary graft dysfunction
  • Risk factors for graft failure:
    • Older donor age
    • Donor left ventricular (LV) dysfunction
    • Longer ischemic time
    • Size mismatch (smaller donor to a larger recipient)
  • Indications include coronary heart disease, non ischemic cardiomyopathies, congenital heart disease
  • Endomyocardial biopsy (EMB) remains the gold standard for rejection surveillance in the heart transplant patient
Prognostic factors
  • 10 year survival rate after cardiac transplantation currently approaches 50% and more in high volume centers
Microscopic (histologic) description
  • Quilty lesions, also known as endocardial lymphocytic infiltrates, are collections of predominantly T lymphocytes with admixed B cells, occasional macrophages and plasma cells seen in the endocardium of transplanted hearts that vary in size from 0.007 to 1.89 mm
  • Acute cellular rejection consists of a mononuclear inflammatory infiltrate that is predominantly a T cell mediated response directed against the cardiac allograft
  • The grades proposed in the ISHLT-WF1990 were mainly based on the amount of inflammatory infiltrate and the presence of myocyte damage
  • 1990 Grading System of the International Society of Heart and Lung Transplantation for Acute Cellular Rejection:
    • Grade 0 (no acute rejection)
    • Grade 1A (focal, mild acute rejection)
    • Grade 1B (diffuse, mild acute rejection)
    • Grade 2 (focal, moderate acute rejection)
    • Grade 3A (multifocal moderate rejection)
    • Grade 3B (diffuse, borderline severe acute rejection)
    • Grade 4 (severe acute rejection)
  • 2004 Grading System of the International Society of Heart and Lung Transplantation for Acute Cellular Rejection:
    • Grade 0R (no acute cellular rejection)
    • Grade 1R (mild, low grade, acute cellular rejection): interstitial and/or perivascular infiltrate with up to 1 focus of myocyte damage
    • Grade 2R (moderate, intermediate grade, acute cellular rejection): 2 or more foci of infiltrate with associated myocyte damage
    • Grade 3R (severe, high grade, acute cellular rejection): diffuse infiltrate with multifocal myocyte damage +/- edema, +/- hemorrhage +/- vasculitis
Microscopic (histologic) images

Images hosted on Other servers:
Missing Image Missing Image Missing Image

Grades of cellular rejection

Missing Image Missing Image

Endocardial lymphocytic infiltrates versus cellular rejection

Missing Image

Ischemic injury

Missing Image

Previous biopsy sites

Missing Image Missing Image Missing Image

Various grading images

Differential diagnosis
  • Ischemic injury:
    • Should be differentiated from cellular rejection
    • The extent of myocyte necrosis is usually out of proportion to the inflammatory infiltrate in ischemic injury, with the infiltrates consisting mostly of neutrophils and macrophages
    • In cellular rejection, the infiltrates are predominantly lymphocytic
  • Previous biopsy site:
    • Will show several stages of healing
    • Recent biopsy sites will show thrombus and granulation tissue
    • Late findings include fibrosis with entrapped myocytes that often exhibit disarray and a variable amount of mononuclear cell infiltrate
    • Old biopsy sites present as endocardial scars
Back to top
Image 01 Image 02