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Hemodynamic impact of coronary stenosis using computed tomography: comparison between noninvasive fractional flow reserve and 3D fusion of coronary angiography with stress myocardial perfusion


Vasodilator-stress CT perfusion imaging in addition to CT coronary angiography (CTCA) may provide a single-test alternative to nuclear stress testing, commonly used to assess hemodynamic significance of stenosis. Another alternative is fractional flow reserve (FFR) calculated from cardiac CT images. We studied the concordance between these two approaches and their relationship to outcomes. We prospectively studied 150 patients with chest pain, who underwent CTCA and regadenoson CT. CTCA images were interpreted for presence and severity of stenosis. Fused 3D displays of subendocardial X-ray attenuation with coronary arteries were created to detect stress perfusion defects (SPD) in each coronary territory. In patients with stenosis > 25%, CT-FFR was quantified. Significant stenosis was determined by: (1) combination of stenosis > 50% with an SPD, (2) CT-FFR ≤ 0.80. Patients were followed-up for 36 ± 25 months for death, myocardial infarction or revascularization. After excluding patients with normal arteries and technical/quality issues, in final analysis of 76 patients, CTCA depicted stenosis > 70% in 13/224 arteries, 50–70% in 24, and < 50% in 187. CT-FFR ≤ 0.80 was found in 41/224 arteries, and combination of SPD with > 50% stenosis in 31/224 arteries. Inter-technique agreement was 89%. Despite high incidence of abnormal CT-FFR (30/76 patients), only 7 patients experienced adverse outcomes; 6/7 also had SPDs. Only 1/9 patients with CT-FFR ≤ 0.80 but normal perfusion had an event. Fusion of CTCA and stress perfusion can help determine the hemodynamic impact of stenosis in one test, in good agreement with CT-FFR. Adding stress CT perfusion analysis may help risk-stratify patients with abnormal CT-FFR.

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Computed tomography


Computed tomography coronary angiography


Computed tomography perfusion


Fractional flow reserve


Hounsfeld units


Left anterior descending


Left circumflex


Left ventricular


Myocardial perfusion imaging


Right coronary artery


Stress-induced perfusion defect


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This study was funded by a research grant from Astellas Pharma Global Development (Grant No. REGA-13H05). Four of the coauthors (AN, AM, AS and KK) were supported by the NIH T32 Cardiovascular Sciences Training Grant (5T32HL7381). HeartFlow provided analyses for free. Dr. Patel and Dr. Lang have research support from Philips for other projects.

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Correspondence to Victor Mor-Avi.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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The study was approved by the Institutional Review Board with a waiver of consent.

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Video 1

Combined 3D display of the coronary arteries obtained from CT angiography and myocardial perfusion obtained by 3D analysis of subendocardial X-ray attenuation and color-encoded onto the end-diastolic endocardial surface, depicting normal, mostly uniform perfusion. This display lends itself to examination of perfusion in the territory of each artery, without the need to mentally reconcile these two types of information in the 3D space. (MOV 21643 kb)

Video 2

Combined 3D display of the coronary arteries and myocardial perfusion obtained in a patient with an intermediate grade stenosis, resulting in 50–60% luminal narrowing in the proximal LAD. A large perfusion abnormality encompassing the antero-septal and septal walls is depicted by the blue color. (MOV 20002 kb)

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Patel, A.R., Maffessanti, F., Patel, M.B. et al. Hemodynamic impact of coronary stenosis using computed tomography: comparison between noninvasive fractional flow reserve and 3D fusion of coronary angiography with stress myocardial perfusion. Int J Cardiovasc Imaging 35, 1733–1743 (2019).

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  • Fusion imaging
  • Cardiovascular CT
  • Vasodilator stress
  • Myocardial perfusion