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Untitled
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
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