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. 2019 Oct 31;1(4):e190036.
doi: 10.1148/ryct.2019190036. eCollection 2019 Oct.

Diagnostic Performance of On-Site Coronary CT Angiography-derived Fractional Flow Reserve Based on Patient-specific Lumped Parameter Models

Robbert W van Hamersvelt  1 , Michiel Voskuil  1 , Pim A de Jong  1 , Martin J Willemink  1 , Ivana Išgum  1 , Tim Leiner  1
Affiliations

Diagnostic Performance of On-Site Coronary CT Angiography-derived Fractional Flow Reserve Based on Patient-specific Lumped Parameter Models

Robbert W van Hamersvelt et al. Radiol Cardiothorac Imaging. .

Abstract

Purpose: To evaluate the diagnostic performance of a prototype on-site coronary CT angiography-derived fractional flow reserve (CT FFR) algorithm, based on patient-specific lumped parameter models, for the detection of functionally significant stenosis defined by invasive FFR, and to compare the performance to anatomic evaluation of stenosis degree.

Materials and methods: In this retrospective feasibility study, 77 vessels in 57 patients (42 of 57 [74%]) men; mean age, 58.5 years ± 9.2 [standard deviation]) who underwent clinically indicated coronary CT angiography within 60 days prior to an invasive FFR measurement were analyzed. Invasive FFR less than or equal to 0.80 was used to indicate a functionally significant stenosis. Diagnostic performance of CT FFR was evaluated and compared with evaluation of stenosis degree. Analysis was performed on a per-vessel basis.

Results: Invasive FFR revealed functionally significant stenoses in 37 vessels (48%). CT FFR showed a significantly increased ability to indicate functionally significant stenosis (area under the receiver operating characteristic curve [AUC], 0.87) compared with degree of stenosis at coronary CT angiography (AUC, 0.70; ΔAUC 0.17; P < .01). Using a cutoff of less than or equal to 0.80 for CT FFR and greater than or equal to 50% degree of stenosis at coronary CT angiography to indicate a significant stenosis, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 33 of 37 (89.2%), 31 of 40 (77.5%), 33 of 42 (78.6%), 31 of 35 (88.6%), and 64 of 77 (83.1%), respectively, for CT FFR, and 33 of 37 (89.2%), 17 of 40 (42.5%), 33 of 56 (58.9%), 17 of 21 (81.0%), and 50 of 77 (64.9%), respectively, for degree of stenosis at coronary CT angiography.

Conclusion: Diagnostic performance of on-site CT FFR was superior to stenosis evaluation at coronary CT angiography for identification of functionally significant coronary artery stenosis in patients suspected of having or known to have coronary artery disease.© RSNA, 2019See also commentary by Schoepf et al.

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Conflict of interest statement

Disclosures of Conflicts of Interest: R.W.v.H. Activities related to the present article: institution supported by grant from Netherlands Organization for Health Research and Development (ZonMw), with participation of Pie Medical Imaging in the framework of the research program IMDI (Innovative Medical Devices Initiative); project 104003009; institution received research prototype CT-FFR software (FFR-CT, IntelliSpace Portal version 9.0.1.20490, Philips Healthcare) free from Philips Healthcare; The University Medical Center Utrecht Department of Radiology receives research support from Philips Healthcare. Activities not related to the present article: disclosed no relevant relationships. Other relationships: disclosed no relevant relationships. M.V. disclosed no relevant relationships. P.A.d.J. Activities related to the present article: The Division of Imaging, UMC Utrecht receives research support from Philips Healthcare. Activities not related to the present article: disclosed no relevant relationships. Other relationships: disclosed no relevant relationships. M.J.W. Activities related to the present article: institution receives money from the American Heart Association (18POST34030192). Activities not related to the present article: disclosed no relevant relationships. Other relationships: consultant for Artery; stockholder in Segmed. I.I. Activities related to the present article: institution receives grant from the Netherlands Organization for Health Research and Development with participation of Pie Medical Imaging in the framework of the research program IMDI (Innovative Medical Devices Initiative); project 104003009. Activities not related to the present article: institution receives research grant from Dutch Technology Foundation with participation of Pie Medical Imaging and Philips Healthcare (program P15-26); research grant with participation of Pie Medical Imaging and 3mensio Medical Imaging (project 12726); and research grant Dutch Cancer Society (KWF); two research grants Pie Medical Imaging; institution has patents (Pie Medical Imaging) US Patent App.15/933,854; one patent pending; as an inventor, author should also receive payments but has received none so far; scientific cofounder and shareholder of Quantib-U. Patents: patent pending for Pie Medical Imaging; patent issued, Pie Medical Imaging, US patent approved 15/933,854 (as inventor, author should also receive payments; none thus far) Other relationships: disclosed no relevant relationships. T.L. Activities related to the present article: institution received grant from Netherlands Organization for Health Research and Development (ZonMw), with participation of Pie Medical Imaging in the framework of the research program IMDI (Innovative Medical Devices Initiative); project 104003009; Activities not related to the present article: institution receives payment for lectures from Philips Healthcare and Bayer Healthcare. Other relationships: Dr Leiner is co-inventor of U.S. patent 10,176,575; this patent is held by Utrecht University Holdings, which manages the terms of any licensing agreement.

Figures

Figure 1:
Figure 1:
Patient flowchart. CCTA = coronary CT angiography, FFR = fractional flow reserve.
Figure 2:
Figure 2:
Example of CT angiography–derived fractional flow reserve (CT FFR) analysis. Coronary CT angiographic curved multiplanar reconstruction of the left anterior descending artery indicated, A, a significant stenosis (white arrow; 50%–69% degree of stenosis). To apply the CT FFR algorithm, first, B, the centerline was automatically segmented and manually corrected where needed; C, D, subsequently, automatic lumen segmentation was performed and also manually corrected where needed. E, This anatomic model of the coronary tree was used as input for the CT FFR algorithm. In this case, CT FFR was 0.75 (black arrow), indicating a significant stenosis (white arrow). F, Findings were confirmed by invasive FFR with a value of 0.76 (black arrow).
Figure 3:
Figure 3:
Receiver operating characteristic (ROC) curves for CT angiography–derived fractional flow reserve (CT FFR) (blue line) and degree of stenosis at coronary CT angiography (CCTA) (red line) with 95% confidence interval bands (blue and red areas) and corresponding area under the ROC curve (AUC) values in, A, all lesions and in, B, intermediate lesions only.
Figure 4:
Figure 4:
Scatterplot of CT angiography–derived fractional flow reserve (CT FFR) and invasive FFR values. Color of the dots indicates degree of stenosis at coronary CT angiography, with low-grade stenosis (<25%, one vessel) in purple, intermediate-degree stenosis (25%–69%, 69 vessels) in blue, and high-grade stenosis (≥70%, seven vessels) in orange. Pearson correlation coefficient for all lesions was r = 0.55 and for intermediate stenosis only r = 0.56. Black lines indicate the cutoff value used for both invasive FFR (0.80) and CT FFR (0.80).
Figure 5:
Figure 5:
Bland-Altman plot of CT angiography–derived fractional flow reserve (CT FFR) and invasive FFR values. Color of the dots indicates degree of stenosis at coronary CT angiography, with low-grade stenosis (<25%, one vessel) in purple, intermediate-degree stenosis (25%–69%, 69 vessels) in blue, and high-grade stenosis (≥70%, seven vessels) in orange. Mean difference was 0.03 for all lesions and 0.02 for intermediate stenosis only, ±1.96 standard deviation (SD) was similar for both groups with an interval of −0.16 to 0.21.
Figure 6:
Figure 6:
Scatterplot of CT angiography–derived fractional flow reserve (CT FFR) and invasive FFR values, subdivided by coronary calcium Agatston score in the vessel of interest. Color of the dots indicates grading of coronary artery calcium Agatston score. Black lines indicate the cutoff value used for both invasive FFR (0.80) and CT FFR (0.80).
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