Heart transplant pathology
Heart transplant pathology is a niche in cardiac pathology.
Overview - table
Types of rejection[1]
| Type (grade) | Description | Details | Image |
| antibody-mediated rejection (acute vascular) | edema, dilated small vessels | scant inflammation | acute |
| normal (0R) | normal | no extravascular monocytes | |
| acute cellular (1R) | perivascular infiltrate, myocyte damage | scant interstitial infiltrate (lymphoplasmic), scant damage | mild cellular |
| acute cellular (2R) | (perivascular) space-occupying lesion | diffuse interstitial infiltrate displaces parenchyma (lymphoplasmic), obvious damage | mod. cellular, mod. cellular resolving |
| acute cellular (3R) | disruption of normal arch. | diffuse interstitial infiltrate disrupts parenchyma (lymphoplasmic & PMNs), fibre loss/damage | |
| chronic | concentric intimal thicking | internal elastic lamina preserved (unlike atherosclerosis) | chronic, chronic |
Pitfalls[1]
| Name | Description | Details | Image |
| Quilty effect | endocardial/subendocardial B-lymphocytes (in clusters) | may extend into myocardium, not assoc. with blood vessels +/-myocyte damage; benign behaviour clinically | Quilty effect, Quilty effect |
| Old biopsy site | hemosiderin-laden macrophages | fibrosis/myocyte replacement | old Bx site |
Mimics
Biopsy site reaction
General
- Can be confused for rejection.
Microscopic
Features:
- Hemosiderin-laden macrophages.
- +/-Fibrosis/myofibre loss-replacement.
- +/-Scant inflammatory infiltration.
Image: Biopsy site (pathconsultddx.com).
Quilty effect
General
- Can be confused for rejection.
- Benign behaviour.
Trivia:
- The name Quilty comes from the patient in which this was first recognized.
Microscopic
Features:
- B-lymphocytes (in clusters).
- Associated with the endocardium ("endothelium of the heart"), i.e. on the surface - key feature.
- Not associated with blood vessels.
Notes:
- No longer subclassified.[2]
- Traditional classification (by location):
- Quilty A: Endocardial/subendocardial.
- Quilty B: Endocardial/subendocardial + myocardium.
- +/-Myocyte damage.[3]
- Traditional classification (by location):
Images:
Coronary atherosclerosis (ischemic injury)
General
- Usu. early - related to atherosclerosis in the donor heart.
- Not typically biopsied. (???)
Microscopic
Features:
- Findings seen in atherosclerosis.
Rejection
It comes in different flavours:[4]
- Antibody-mediate rejection (acute vascular rejection).
- Acute cellular rejection.
- Chronic rejection.
Antibody-mediated rejection
- Abbreviated as AMR.
General
Microscopic
Features:[6]
- Edema.
- Dilated small vessels.
- Scant inflammatory infiltrate.
Image:
IHC
Features:[2]
- C4d.
- C3d.
Acute cellular rejection
Grading scheme 2004/1990:[7]
| Grade 2004 | Grade 1990 | Description | Details | Image |
| 0R | 0 | normal | no extravascular monocytes | |
| 1R | 1A | infiltrate, myocyte damage | scant interstitial infiltrate (lymphoplasmic), scant damage | mild |
| 1R | 1B | infiltrate, myocyte damage | diffuse interstitial infiltrate (lymphoplasmic), focal damage | |
| 1R | 2 | infiltrate, myocyte damage | diffuse interstitial infiltrate (lymphoplasmic), obvious damage | |
| 2R | 3A | space-occupying lesion | diffuse interstitial infiltrate displaces parenchyma (lymphoplasmic), obvious damage | mod., mod. resolving |
| 3R | 3B | disruption of normal arch. | diffuse interstitial infiltrate disrupts parenchyma (lymphoplasmic & PMNs), obvious damage | |
| 3R | 4 | disruption of normal arch. | diffuse interstitial infiltrate disrupts parenchyma (lymphoplasmic & PMNs), fibre loss |
Chronic rejection
General
- AKA transplant arteriopathy or cardiac allograft vasculopathy.
- Thought to be a form of accelerated atherosclerosis.[8]
Microscopic
Features:[9]
- Concentric intimal thickening.
- Preservation of internal elastic lamina.
Images:
Notes:
- Morphologically vaguely similar to atherosclerosis.
Other
Post-transplant lymphoproliferative disorder
Main article: Post-transplant lymphoproliferative disorder
- Abbreviated PTLD.
General
- Rare.
- Associated with EBV.[11]
Microscopic
Features:
- Large cell lymphoma - see DLBCL.
See also
References
- ↑ 1.0 1.1 Humphrey, Peter A; Dehner, Louis P; Pfeifer, John D (2008). The Washington Manual of Surgical Pathology (1st ed.). Lippincott Williams & Wilkins. pp. 136-7. ISBN 978-0781765275.
- ↑ 2.0 2.1 2.2 2.3 Tan CD, Baldwin WM, Rodriguez ER (August 2007). "Update on cardiac transplantation pathology". Arch. Pathol. Lab. Med. 131 (8): 1169–91. PMID 17683180.
- ↑ Winters GL (March 1997). "The challenge of endomyocardial biopsy interpretation in assessing cardiac allograft rejection". Curr. Opin. Cardiol. 12 (2): 146–52. PMID 9192483.
- ↑ URL: http://emedicine.medscape.com/article/1612493-overview. Accessed on: 9 Febraury 2011.
- ↑ Olsen SL, Wagoner LE, Hammond EH, et al. (1993). "Vascular rejection in heart transplantation: clinical correlation, treatment options, and future considerations". J. Heart Lung Transplant. 12 (2): S135–42. PMID 8476883.
- ↑ URL: http://www.pathconsultddx.com/pathCon/largeImage?pii=S1559-8675%2806%2970592-7&figureId=fig4. Accessed on: 7 January 2011.
- ↑ Humphrey, Peter A; Dehner, Louis P; Pfeifer, John D (2008). The Washington Manual of Surgical Pathology (1st ed.). Lippincott Williams & Wilkins. pp. 136. ISBN 978-0781765275.
- ↑ Humphrey, Peter A; Dehner, Louis P; Pfeifer, John D (2008). The Washington Manual of Surgical Pathology (1st ed.). Lippincott Williams & Wilkins. pp. 137. ISBN 978-0781765275.
- ↑ URL: http://www.pathconsultddx.com/pathCon/largeImage?pii=S1559-8675%2806%2970592-7&figureId=fig5. Accessed on: 7 January 2011.
- ↑ URL: http://newsroom.ucla.edu/portal/ucla/ucla-team-uncovers-mechanism-behind-179330.aspx. Accessed on: 7 January 2011.
- ↑ URL: http://emedicine.medscape.com/article/431364-overview. Accessed on: 10 February 2011.