Background: Coronary artery disease (CAD) is  a common comorbidity in patients suffering from terminal lung disease and a recurrent problem in pre-transplant evaluation. Historically, CAD has been treated as a contraindication for lung transplantation, however more and more evidence suggests that CAD in well selected patients might not be associated with a worse outcome following lung transplantation. In its 2020 consensus document for the selection of lung transplant candidates, the International Society for Heart and Lung Transplantation (ISHLT) states that CAD should not be considered an absolute contraindication but a potential marker for an unfavourable phenotype. However, data backing up this decision is limited and in parts inconclusive. This study therefore aims to provide solid data on the relevance of pre-existing CAD in the setting of lung transplantation as well as a defining additional risk factors and their importance for posttransplantation survival . 

Methods: 1003 patients receiving single or double lung transplantation at the LMU hospital Munich between January 2000 and August 2021 were included in this study, resulting in the biggest study population concerning CAD in lung transplantation to date. The median follow up was 3.24 years [1.30, 4.82]. Plaque formation in the coronary arteries was identified by coronary angiography in 230 patients. A relevant CAD  defined by stenosis >50% or previous percutaneous coronary intervention/coronary artery bypass graft was present in 104 patients (CAD group).

Results: Baseline characteristics of the CAD group differed significantly from the non-CAD group in terms of Age at Transplantation  [y] (60.28 [56.71, 63.24] vs. 53.96 [44.45, 59.85], p<0.001), Sex  [male] (74.0% vs. 52.3%, p<0.001) and BMI  [kg/m2] (24.13 [21.25, 27.41] vs 22.22 [19.37, 25.62], p<0.001) as well as the abundance of cardiovascular risk factors  including hypertension (67.3% vs 32.1%, p<0.001) and smoking (67.3% vs 40.9%, p<0.001). Therefore 1:1 propensity score matching was performed, resulting in 98 matched pairs. Matching variables, including demographics, cardiovascular risk factors, results from the right heart catheter and lung testing, were well balanced without significant differences between the groups . The primary endpoint overall survival was similar in the matched groups  HR=0.94, 95% CI 0.64-1.39, p=0.80. In addition, no significant differences in intrahospital mortality (8.2% vs 5.1%, p=0.566) could be detected.  Furthermore, there was no significant difference in the occurrence of myocardial infarction  (6.1% vs 4.1%, p=0.745) or stroke (2.0% vs 5.1%, p=0.441) following transplantation. 

Conclusion: The finding of this study provides further evidence indicating that CAD itself may not be associated with worse survival following lung transplantation.  Careful evaluation and patient selection can allow patients suffering from CAD to successfully undergo lung transplantation without inferior survival.