Diagnostic performance of non-invasive fractional flow reserve derived from coronary computed tomography angiography: current perspectives

摘要

Coronary computed tomography angiography (CTA) has been increasingly used to detect coronary artery disease. The diagnostic performance of coronary CTA is well established with a high sensitivity and negative predictive value. Nevertheless, the diagnostic value of coronary CTA is offset by a high false positive rate, partly due to the technique lacking physiological lesion assessment when performed in the conventional way. This has raised concerns regarding unnecessary invasive coronary angiography referrals and inappropriate revascularization procedures. Recent advances in computational fluid dynamics and image-based modeling have enabled the calculation of coronary artery blood flow and pressure under various modeled physiologic conditions from coronary CTA without the need for hyperemia-inducing medications, modification of acquisition protocol or further radiation. Coronary flow and pressure can be derived both at rest and during simulated maximum hyperemia allowing for the calculation of fractional flow reserve from coronary CTA (FFR_CTA) across stenotic lesions in a fashion similar to invasive FFR. This novel non-invasive technology offers concurrent anatomical and functional assessment of major epicardial coronary arteries. The diagnostic performance of FFR_CTA has been tested in three major trials where it resulted in accurate identification of ischemia-related lesions. Similar to an invasive FFR-guided management strategy, the use of FFR_CTA has been shown to improve patients' outcomes and reduce health care costs. FFR_CTA is emerging as an attractive alternative to invasive FFR. There are, however, several challenges that need to be overcome before FFR_CTA can be incorporated into routine clinical practice.