Cardiac allograft vasculopathy (CAV) is characterized by marked intimal proliferation and concentric vascular thickening and fibrosis. CAV remains the leading cause of late morbidity and mortality in heart transplant recipients. Optical coherence tomography (OCT) is a new generation catheter-based modality that acquires images at a spatial resolution of 10-20 μm which is 10-fold greater than that of intravascular ultrasound (IVUS). OCT is currently the most sensitive imaging technique for early CAV detection. Recent studies proved that circulating human leukocyte antigen (HLA) directed donor-specific antibodies correlate with increased mortality and CAV. Contradiction of scientific results has been reported regarding increased resting heart rate and development of CAV. Larger prospective studies using more sensitive CAV detecting methods are required to enhance our understanding. Novel immunosuppressants, mechanistic target of rapamycin (mTOR) inhibitors, may attenuate CAV progression and may improve long-term allograft survival owing to favorable coronary remodeling.