Coronary allograft vasculopathy (CAV), a disease characterized by the development of progressive fibroproliferation within the coronary arteries of transplant recipients, remains a dominant cause of late morbidity and mortality among those undergoing cardiac transplantation. Owing to the serious and potentially fatal nature of CAV, routine surveillance for CAV is recommended with annual or biannual coronary angiography. As is true for the detection of native coronary artery disease in non-transplant recipients, coronary angiography for the detection of CAV is limited by a low sensitivity, a problem exacerbated by the ability of the coronary arteries to positively remodel to maintain lumen dimensions as CAV progresses. Intracoronary imaging with intravascular ultrasound (IVUS) offers improved sensitivity for CAV detection and is applied routinely at some centers 4 to 6 weeks after transplantation to rule out donor coronary artery disease and again at 1 year to detect the development of rapidly progressive CAV. Defined by IVUS imaging as the progression of maximal intimal thickness (MIT) of ≥0.5 mm at 1 year compared to the baseline study performed 4 to 6 weeks after transplantation, rapidly progressive CAV is associated with a significant increase in morbidity and mortality during long-term follow up and often prompts a change in immunosuppressive therapy in an attempt to slow CAV progression.