Cardiac transplantation as a treatment for end stage cardiac failure has become widely accepted, and numerous centres carry out this procedure worldwide. Survival figures have generally improved over the years; the most recent International Society for Heart and Lung Transplantation (ISHLT) registry figures show an overall one year survival of 79% and a patient half life (time to 50% survival) of 8.6 years.1 Improvements in survival are likely to be multifactorial with the introduction of cyclosporin A undoubtedly being a milestone in immunosuppression. Apart from improvements in immunosuppression, adherence to carefully constructed protocols within transplant centres for patient management has contributed to improvements in quality of life and overall survival. In spite of numerous attempts to find alternative and non-invasive means of monitoring patients, principally for the presence of acute rejection, endomyocardial biopsy remains the gold standard for patient follow up.

Endomyocardial biopsy protocols, with frequent biopsies in the early months and standardised treatments for particular clinical situations, are important in the management of patients. A key element in relation to endomyocardial biopsies is that microscopic appearance of the biopsy specimens should be translated readily into appropriate management. An important component of this is the grading of any rejection in biopsy specimens. Billingham made a decisive contribution to heart transplantation with the introduction of her grading system for cardiac rejection.2 This system was successfully applied for many years in many units and provided a framework for communication between the reporting pathologists and clinicians managing patients. Some fine tuning was proposed to this grading system and many centres worldwide subsequently chose to modify it, or use their own in-house grading systems.3 ,4 Because of an increasing disparity between grading systems used worldwide, and because of the need to standardise diagnosis and compare results between different centres—not least …