Noninvasive Fractional Flow Reserve Derived From Coronary CT Angiography

Abstract

Fractional flow reserve derived from coronary computed tomography angiography enables noninvasive assessment of the hemodynamic significance of coronary artery lesions and coupling of the anatomic severity of a coronary stenosis with its physiological effects. Since its initial demonstration of feasibility of use in humans in 2011, a significant body of clinical evidence has developed to evaluate the diagnostic performance of coronary computed tomography angiography-derived fractional flow reserve compared with an invasive fractional flow reserve reference standard. The purpose of this paper was to describe the scientific principles and to review the clinical data of this technology recently approved by the U.S. Food and Drug Administration.

Clinical Quantification of Myocardial Blood Flow Using PET: Joint Position Paper of the SNMMI Cardiovascular Council and the ASNC

“…Noninvasive estimation of FFR using CT has also recently been described. 182 Although both FFR and MFR can be used to assess the functional significance of stenosis, what they actually measure, their physiologic basis, and their clinical implications are distinct.…”

Fractional Flow Reserve and Coronary Computed Tomographic Angiography

“…In this context, evaluation of FFRCT as a gatekeeper to ICA will be examined by Coronary Computed Tomographic Angiography for Selective Cardiac Catheterization (CONSERVE). 30 However, the 79% specificity is still suboptimal, and the lower sensitivity is of concern. The PPV and NPV, which are dependent on the prevalence of ischemic lesions in the specific patient population and cannot be easily extrapolated to the community at large, were 65% and 93% for CT-FFR versus 40% and 92% for CTA alone.…”

“…Computed Tomographic Evaluation of Atherosclerotic Determinants of Myocardial Ischemia (CREDENCE) 30 will be a direct comparison of CTA plus FFRCT against MPI and positron emission tomography. PERFECTION will pit FFRCT against single-energy CT rest/ stress perfusion imaging 30 and Dual Energy CT for Ischemia Determination Compared to "Gold Standard" Non-Invasive and Invasive Technique (DECIDE-Gold) will compare FFRCT and dual-energy CT rest/stress perfusion imaging. 30 However, these are trials of diagnostic performance, rather than patient outcomes.…”

“…PERFECTION will pit FFRCT against single-energy CT rest/ stress perfusion imaging 30 and Dual Energy CT for Ischemia Determination Compared to "Gold Standard" Non-Invasive and Invasive Technique (DECIDE-Gold) will compare FFRCT and dual-energy CT rest/stress perfusion imaging. 30 However, these are trials of diagnostic performance, rather than patient outcomes.…”

“…Although CTA has been shown to increase the revascularization rate compared with usual care, 24,25 the incremental role of CT-FFR on the number of revascularizations is unknown, and there are no outcome studies to determine the beneficial effect of CT-FFR-guided revascularization. The prognostic significance of FFRCT will be evaluated by Assessing Diagnostic Value of Non-Invasive FFRCT in Coronary Care (ADVANCE) 30 in a prospective longitudinal registry.…”