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Allograft Heart Template
(2 H & E)
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1. Total fragments( )
2. Fragments of endomyocardium( )
3. Fragments with inflammation( )
4. Greatest degree of inflammation( ) None( ) Mild( ) Moderate( ) Severe
5. Location of inflammation( ) N/A( ) Endocardial( ) Perivascular( ) Interstitial
6. Eosinophils (>10/hpf in most areas)( ) No( ) Yes
7. Myocyte necrosis/dropout( ) No( ) Yes
8. Venulitis( ) No( ) Yes
9. Arteritis (necrotizing or inflammatory)( ) No( ) Yes
10. Interstitial hemorrhage( ) No( ) Yes
11. Infectious agents( ) No( ) Yes
11a. if yes, specify:
12. Quilty lesion( ) No( ) Yes
13. Type( ) N/A( ) Endocardial( ) Perivascular( ) Epicardial( ) Infiltrating
14. Fibrosis severity( ) None( ) Mild( ) Moderate( ) Severe
15. Fibrosis location( ) N/A( ) Endocardial( ) Interstitial( ) Both
16. Other findings:
17. IHLTS Grade:( ) 0( ) 1A( ) 1B( ) 2( ) 3A( ) 3B
( ) 4( ) 5
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Last Modified: Thu Jun 18 10:14:08 EDT 2009