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A Classification of Cardiac Allograft Rejection: A Modification of the Classification by Billingham

We herein propose a classification of rejection in cardiac allografts based on the original Stanford work. Our modified classification, as a work hypothesis, defines the following grades: (a) mild acute rejection (A-l), corresponding to Billingham's “mild rejection”; (b) mild acute rejection with probable conversion to moderate rejection (A-2); (c) moderate acute rejection (A-3), comparable to Billingham's “moderate rejection”; and (d) severe acute rejection (A-4), morphologically identical with the respective grade in the Billingham classification. The resolution of rejection has been classified into two grades— early (A-5a) and late (A-5b) resolution—according to the development of granulation tissues. We also grade the degree of vasculopathy (B-l, B-2) and chronic rejection (C), which is characterized by aggressive fibrosis and persistent vasculopathy. Mild rejection with possible conversion to moderate rejection is defined by an increasing quantity of retrogressive changes in myocytes. Changes not related to transplantation are characterized in our classification by descriptive diagnosis. The proposed classification was validated by 1 year of clinical experience and by the evaluation of possible prognostic aspects of the classification.