Objective: The rational of this study was to investigate explanted failing grafts in the light of new concepts in rejection mechanisms, namely AMR. Method: This retrospective multicentric study collected 31 explanted cardiac grafts failing ≥1 year posttransplantation. The vasculature of the grafts was assessed from epicardial coronary arteries to myocardial microcirculation. Immunohistochemistry was performed for C4d complement fraction deposition and CD68-positive macrophages in the explanted grafts and previous endomyocardial biopsies. Donor specific antibodies (DSA) were retrospectively assessed using Luminex SA technique. Results: A pure classical coronary atherosclerosis pattern was observed in 6/31 (19 %). A pure pattern of CAV was present in 12/31 (39 %) and a mixed pattern associating CAV and atherosclerosis features in 9/31 (29 %). Interestingly the CAV pure and mixed patterns were associated with vascular inflammation within the arteries and/or the microcirculation with C4d deposits and macrophages (15/21) in the explanted grafts versus nil (0/6) in pure atherosclerosis pattern (p<0.002). Furthermore they were associated with previous AMR episodes on endomyocardial biopsies (11/ 21) and by positive DSA (10/14) versus nil in pure atherosclerosis pattern (p<0.05 and p=0.05, respectively). Conclusion: In failing cardiac grafts CAV lesions are associated with makers of AMR. CAV should be the consequence in coronary arteries of an ongoing AMR process. Results: In our cases increase in fibrous and adipose tissue concordant with age, indicating an age related nature, were detected. Fibrous and fatty tissue infiltration appeared at the age of 35. Fatty infiltration started at the age between 20 and 34 at sinoatrial node. In 4 cases calcification and in 19 cases inflammation was observed. Amyloid accumulation was not present. In 7 cases myocardial infarction not involving CCS was seen. In 1 case fibroelastoma was detected. Conclusion: In Turkish population age related fibrosis and fatty infiltration in CCS appeared at the age of 35 and increased with age. Fatty infiltration in sinoatrial node started at a younger age than that of reported in the literature. In cases whom the cause of death could not be determined we could not detect lethal pathologic features. However we think that examination of the CCS will improve the quality of autopsy diagnosis.