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Cardiac allograft vasculopathy (CAV) is a complex disease of the vasculature of the grafted heart. It is the major cause of graft loss and mortality 1 year posttransplantation. Imaging techniques are the main tools for detecting and classifying CAV. The disease typically involves the epicardial coronary arteries and spreads into the intramyocardial branches. Pathologic features are heterogeneous and include concentric proliferative intimal lesions and vascular inflammation, which can be associated with conventional atherosclerotic plaques. The involvement of the small arteries and the microcirculation, the microvasculopathy, is responsible for structural and functional changes. Among the multiple risk factors associated with CAV, antibody-mediated rejection is currently recognized as the principle.