Interpreting results of coronary computed tomography angiography-derived fractional flow reserve in clinical practice

Rabbat, Mark; Berman, Daniel S.; Kern, Morton J.; Raff, Gilbert; Chinnaiyan, Kavitha M.; Koweek, Lynne; Shaw, Leslee J.; Blanke, Philipp; Scherer, M; Jensen, Jesper Møller; Lesser, John R.; Nørgaard, Bjarne Linde; Pontone, Gianluca; Bruyne, Bernard De; Bax, Jeroen J.; Leipsic, Jonathon

doi:10.1016/j.jcct.2017.06.002

Cited by 49 publications

(40 citation statements)

References 29 publications

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“…Distal Vessel FFR CT Values FFR CT provides simultaneous computation of pressure and flow in the entire coronary tree, thus exposing both lesion-specific pressure as well as nadir FFR CT values across the coronary system, which in various settings may drop less than or equal to 0.80 (14,19,(34)(35)(36) (Fig 1). Low terminal vessel FFR CT values (rather than a value distal to stenosis) may include effects unrelated to the stenosis (19,(35)(36)(37). These low values remote from a focal lesion may be due to diffuse CAD or reflect the sum of serial flow-limiting lesions (35)(36)(37).…”

Section: Nørgaard Et Almentioning

confidence: 99%

“…In patients with CAD, as for measured FFR, FFR CT values decline from the ostium to the distal vessel irrespective of the vessel territory, stenosis severity, and location (14,19,(34)(35)(36). In FFR practice, it is advised that the FFR value within the throat of the lesion (which may correspond to the minimum FFR CT value) is not used clinically and that the pressure is assessed at least 2-3 cm distal to the stenosis of interest (20).…”

Section: Standardized Interpretation Of Hemodynamically Significant Lmentioning

confidence: 99%

“…FFR CT assessment is increasingly used in mainstream clinical practice (9)(10)(11)(12)(13)(14) and is likely to further expand with the increased utilization of coronary CT angiography as a first-line test in patients suspected of having coronary artery disease (CAD). While there has been much focus on the diagnostic performance and potential clinical utility of FFR CT in patients with moderate CAD (9)(10)(11)(12)(13)(14)(15)(16)(17)(18), there has been less focus on interpretation, reporting, and integration of FFR CT results into routine clinical practice (19). A broadly adopted standardized FFR CT interpretation and reporting approach providing rich and consistent information may facilitate more appropriate clinical implementation and stimulate further high-quality research.…”

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confidence: 99%

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Coronary CT Angiography-derived Fractional Flow Reserve Testing in Patients with Stable Coronary Artery Disease: Recommendations on Interpretation and Reporting

Nørgaard¹,

Fairbairn²,

Safian³

et al. 2019

Radiology: Cardiothoracic Imaging

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Noninvasive fractional flow reserve derived from coronary CT angiography (FFR CT ) is increasingly used in patients with coronary artery disease as a gatekeeper to the catheterization laboratory. While there is emerging evidence of the clinical benefit of FFR CT in patients with moderate coronary disease as determined with coronary CT angiography, there has been less focus on interpretation, reporting, and integration of FFR CT results into routine clinical practice. Because FFR CT analysis provides a plethora of information regarding pressure and flow across the entire coronary tree, standardized criteria on interpretation and reporting of the FFR CT analysis result are of crucial importance both in context of the clinical adoption and in future research. This report represents expert opinion and recommendation on a standardized FFR CT interpretation and reporting approach.Published under a CC BY 4.0 license.

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Section: Nørgaard Et Almentioning

confidence: 99%

Section: Standardized Interpretation Of Hemodynamically Significant Lmentioning

confidence: 99%

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confidence: 99%

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Coronary CT Angiography-derived Fractional Flow Reserve Testing in Patients with Stable Coronary Artery Disease: Recommendations on Interpretation and Reporting

Nørgaard¹,

Fairbairn²,

Safian³

et al. 2019

Radiology: Cardiothoracic Imaging

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“…A patient-specific three-dimensional model of the coronary arteries is created after segmentation of the CTA data. Using the above-mentioned mathematical assumptions, a supercomputer performs complex post-processing to solve the equations governing fluid dynamics and blood flow [97,101]. Simulated hyperemic blood flow and pressure data are then generated, and the results are sent back to the referring institution within a few hours (Fig.…”

Section: Technology Of Ct-ffrmentioning

confidence: 99%

Computed tomographic evaluation of myocardial ischemia

et al. 2020

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Myocardial ischemia is caused by a mismatch between myocardial oxygen consumption and oxygen delivery in coronary artery disease (CAD). Stratification and decision-making based on ischemia improves the prognosis in patients with CAD. Non-invasive tests used to evaluate myocardial ischemia include stress electrocardiography, echocardiography, single-photon emission computed tomography, and magnetic resonance imaging. Invasive fractional flow reserve is considered the reference standard for assessment of the hemodynamic significance of CAD. Computed tomography (CT) angiography has emerged as a first-line imaging modality for evaluation of CAD, particularly in the population at low to intermediate risk, because of its high negative predictive value; however, CT angiography does not provide information on the hemodynamic significance of stenosis, which lowers its specificity. Emerging techniques, e.g., CT perfusion and CT-fractional flow reserve, help to address this limitation of CT, by determining the hemodynamic significance of coronary artery stenosis. CT perfusion involves acquisition during the first pass of contrast medium through the myocardium following pharmacological stress. CTfractional flow reserve uses computational fluid dynamics to model coronary flow, pressure, and resistance. In this article, we review these two functional CT techniques in the evaluation of myocardial ischemia, including their principles, technology, advantages, limitations, pitfalls, and the current evidence.

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“…24–30 Another possibility is the recently developed and validated fluid dynamics based calculation of fractional flow reserve (FFR) from resting cardiac CT images (CT-FFR), 31–40 which is rapidly expanding into clinical practice. 41,42 Accordingly, this study was designed to validate resting strain abnormalities as a marker of hemodynamically significant stenosis against two reference standards: a combination of stenosis >50% on CTCA concomitant with an SPD, reflecting together the anatomic severity and the hemodynamic impact of stenosis (reference standard A), 43 and a combination of abnormal CT-FFR with an SPD in the same coronary territory, reflecting the hemodynamic impact in a more robust way than either one of its two components alone (reference standard B).…”

Section: Methodsmentioning

confidence: 99%

Fusion of Three-Dimensional Echocardiographic Regional Myocardial Strain with Cardiac Computed Tomography for Noninvasive Evaluation of the Hemodynamic Impact of Coronary Stenosis in Patients with Chest Pain

Mor‐Avi

Patel

Maffessanti

et al. 2018

Journal of the American Society of Echocardiography

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Background Combined evaluation of coronary stenosis and the extent of ischemia is essential in patients with chest pain. Intermediate-grade stenosis on computed tomographic coronary angiography (CTCA) frequently triggers downstream nuclear stress testing. Alternative approaches without stress and/or radiation may have important implications. Myocardial strain measured from echocardiographic images can be used to detect subclinical dysfunction. The authors recently tested the feasibility of fusion of three-dimensional (3D) echocardiography–derived regional resting longitudinal strain with coronary arteries from CTCA to determine the hemodynamic significance of stenosis. The aim of the present study was to validate this approach against accepted reference techniques. Methods Seventy-eight patients with chest pain referred for CTCA who also underwent 3D echocardiography and regadenoson stress computed tomography were prospectively studied. Left ventricular longitudinal strain data (TomTec) were used to generate fused 3D displays and detect resting strain abnormalities (RSAs) in each coronary territory. Computed tomographic coronary angiographic images were interpreted for the presence and severity of stenosis. Fused 3D displays of subendocardial x-ray attenuation were created to detect stress perfusion defects (SPDs). In patients with stenosis >25% in at least one artery, fractional flow reserve was quantified (HeartFlow). RSA as a marker of significant stenosis was validated against two different combined references: stenosis >50% on CTCA and SPDs seen in the same territory (reference standard A) and fractional flow reserve < 0.80 and SPDs in the same territory (reference standard B). Results Of the 99 arteries with no stenosis >50% and no SPDs, considered as normal, 19 (19%) had RSAs. Conversely, with stenosis >50% and SPDs, RSAs were considerably more frequent (17 of 24 [71%]). The sensitivity, specificity, and accuracy of RSA were 0.71, 0.81, and 0.79, respectively, against reference standard A and 0.83, 0.81, and 0.82 against reference standard B. Conclusions Fusion of CTCA and 3D echocardiography–derived resting myocardial strain provides combined displays, which may be useful in determination of the hemodynamic or functional impact of coronary abnormalities, without additional ionizing radiation or stress testing.

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Interpreting results of coronary computed tomography angiography-derived fractional flow reserve in clinical practice

Cited by 49 publications

References 29 publications

Coronary CT Angiography-derived Fractional Flow Reserve Testing in Patients with Stable Coronary Artery Disease: Recommendations on Interpretation and Reporting

Coronary CT Angiography-derived Fractional Flow Reserve Testing in Patients with Stable Coronary Artery Disease: Recommendations on Interpretation and Reporting

Computed tomographic evaluation of myocardial ischemia

Fusion of Three-Dimensional Echocardiographic Regional Myocardial Strain with Cardiac Computed Tomography for Noninvasive Evaluation of the Hemodynamic Impact of Coronary Stenosis in Patients with Chest Pain

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