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. 2020 Feb 24;9(2):604.
doi: 10.3390/jcm9020604.

Fractional Flow Reserve Derived from Coronary Computed Tomography Angiography Safely Defers Invasive Coronary Angiography in Patients with Stable Coronary Artery Disease

Mark Rabbat  1 , Jonathon Leipsic  2 , Jeroen Bax  3 , Brian Kauh  4 , Rina Verma  1 , Demetrios Doukas  1 , Sorcha Allen  1 , Gianluca Pontone  5 , David Wilber  1 , Verghese Mathew  1 , Campbell Rogers  6 , John Lopez  1
Affiliations

Fractional Flow Reserve Derived from Coronary Computed Tomography Angiography Safely Defers Invasive Coronary Angiography in Patients with Stable Coronary Artery Disease

Mark Rabbat et al. J Clin Med. .

Abstract

Objectives: In the United States, the real-world feasibility and outcome of using fractional flow reserve from coronary computed tomography angiography (FFRCT) is unknown. We sought to determine whether a strategy that combined coronary computed tomography angiography (CTA) and FFRCT could safely reduce the need for invasive coronary angiography (ICA), as compared to coronary CTA alone.

Methods: The study included 387 consecutive patients with suspected CAD referred for coronary CTA with selective FFRCT and 44 control patients who underwent CTA alone. Lesions with 30-90% diameter stenoses were considered of indeterminate hemodynamic significance and underwent FFRCT. Nadir FFRCT ≤ 0.80 was positive. The rate of patients having ICA, revascularization and major adverse cardiac events were recorded.

Results: Using coronary CTA and selective FFRCT, 121 patients (32%) had at least one vessel with ≥50% diameter stenosis; 67/121 (55%) patients had at least one vessel with FFRCT ≤ 0.80; 55/121 (45%) underwent ICA; and 34 were revascularized. The proportion of ICA patients undergoing revascularization was 62% (34 of 55). The number of patients with vessels with 30-50% diameter of stenosis was 90 (23%); 28/90 (31%) patients had at least one vessel with FFRCT ≤ 0.80; 8/90 (9%) underwent ICA; and five were revascularized. In our institutional practice, compared to coronary CTA alone, coronary CTA with selective FFRCT reduced the rates of ICA (45% vs. 80%) for those with obstructive CAD. Using coronary CTA with selective FFRCT, no major adverse cardiac events occurred over a mean follow-up of 440 days.

Conclusion: FFRCT safely deferred ICA in patients with CAD of indeterminate hemodynamic significance. A high proportion of those who underwent ICA were revascularized.

Keywords: computational fluid dynamics; coronary computed tomography angiography; fractional flow reserve; stable coronary artery disease.

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Conflict of interest statement

M.R.: Consultant, HeartFlow; J.L.: Consultant, HeartFlow; J.B.: none; B.K.: none; S.A.: none; D.D.: none; R.V.: none; G.P.: Research grants, HeartFlow; D.W.: none; V.M.: none; C.R.: Employee, HeartFlow; J.L.: none.

Figures

Figure 1
Figure 1
Fractional flow reserve from coronary computed tomography angiography (FFRCT) results stratified according to computed tomography angiography stenosis diameter reduction. Nadir FFRCT ≤ 0.80 was positive. Nadir FFRCT > 0.80 was negative.
Figure 2
Figure 2
Distribution of diameter stenosis, fractional flow reserve from coronary computed tomography angiography (FFRCT) and revascularization. (A) Boxplots and scatterplots of FFRCT value by stenosis category. (B) Boxplots and scatterplots of FFRCT value by revascularization.
Figure 3
Figure 3
Flowchart for patients with intermediate coronary artery disease and fractional flow reserve from coronary computed tomography angiography (FFRCT) availability. CTA, computed tomography angiography datasets; ICA, invasive coronary angiography; PCI, percutaneous coronary intervention; CABG, coronary artery bypass graft surgery; MT, medical therapy.
Figure 4
Figure 4
Outcome of invasive coronary angiography (ICA) or revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG) according to fractional flow reserve derived from coronary computed tomographic angiography (FFRCT) positivity.
Figure 5
Figure 5
Study patient case. A 48-year-old male with a family history of coronary artery disease, dyspnea on exertion and atypical chest pain underwent coronary CTA. Multiplanar reformat of coronary CTA of the RCA (A), and FFRCT (B). RCA demonstrated proximal and mid-calcified and non-calcified intermediate (50–70%) stenoses (red arrows) without evidence of lesion-specific ischemia. FFRCT values distal to the proximal and mid RCA stenoses were 0.93 and 0.85, respectively. The patient safely avoided ICA and has been asymptomatic in follow-up on optimal medical therapy. FFRCT, fractional flow reserve derived from coronary computed tomography angiography (CTA) datasets; RCA, right coronary artery; ICA, invasive coronary angiography.
Figure 6
Figure 6
Study patient case. A 48-year-old male with hypertension, diabetes, dyspnea on exertion and atypical chest pain underwent coronary CTA. Multiplanar reformat of coronary CTA of the LAD (A), FFRCT (B), ICA pre- (C) and post- (D) PCI. LAD demonstrated a mid-calcified and non-calcified intermediate (50–70%) stenosis and a distal non-calcified intermediate (50–70%) stenosis (red and purple arrows), with evidence of lesion-specific ischemia. FFRCT values distal to the mid and distal LAD stenoses were 0.78 and 0.72, respectively. The patient underwent successful PCI (green and yellow arrows) of the mid and distal LAD stenoses (orange and blue arrows). FFRCT, fractional flow reserve derived from coronary computed tomography angiography (coronary CTA) datasets; ICA, invasive coronary angiogram; LAD, left anterior descending artery; PCI, percutaneous coronary intervention.
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