Purpose Prior to the advent of direct-acting antivirals (DAAs), donor-derived hepatitis C (dd-HCV) viremia predicted poor post-heart transplant (HT) outcomes, including a higher risk of coronary allograft vasculopathy (CAV) and death. Considering the success of DAAs to treat HCV and the shortage of organs for HT, we institutionalized a clinical protocol of using HCV+ donors. Using intracoronary ultrasound (ICUS) in patients acquiring post-HT HCV infection, we examined the risk of CAV in the current era. Methods Between September 1st 2016 and October 2nd 2018, 54 HCV-naive patients and 1 with a history of treated-HCV pre-transplant, underwent HT from HCV-positive donors (follow-up available through October 10th, 2018). Patients were treated with ledipasvir-sofosbuvir (genotype 1) or sofosbuvir-velpatasvir (genotype 3) for 12 or 24 weeks. ICUS of left anterior descending artery was performed at 6-months and 1-year post-HT for those developing donor-derived HCV (dd-HCV) infection using an automated, mechanical pullback at a rate of 1 mm/ second. Results The ICUS data were available for 20 patients at 6-months (cohort A) and 16 patients at 1-year (cohort B); 14 patients had serial data available at 6-months and 1-year (cohort C). Figures A and B show changes in maximum intima thickness (MIT) for the overall sample and cohort C. For cohort C, absolute change in MIT from 6-months to 1-year was +0.15 (median) (Inter-quartile range: -0.03, 0.42) and only one patient had an increase in MIT by >0.5mm. Two patients in cohort A (10%) and 4 patients in cohort B (25%) had angiographic CAV grade 1; one patient in each cohort had known coronary artery disease in the donor heart. None required percutaneous coronary intervention or re-transplant for CAV at 1-year. Conclusion Utilization of HCV-positive donors may represent a viable strategy to expand the donor pool in era of DAAs. Larger scale data on changes in MIT is required to appropriately assess the effect of dd-HCV infection on incident CAV.