Netherlands Heart Journal

, Volume 20, Issue 10, pp 410–418

CT fractional flow reserve: the next level in non-invasive cardiac imaging

  • M. F. L. Meijs
  • M. J. Cramer
  • H. El Aidi
  • P. A. Doevendans
Review Article

Abstract

The haemodynamic effect of a coronary artery stenosis is a better predictor of prognosis than anatomical lumen obstruction. Until recently, no individual non-invasive test could provide both accurate coronary anatomy and lesion-specific myocardial ischaemia. However, computer tomography (CT) fractional flow reserve, which can be calculated from a standard CT coronary angiogram, was recently demonstrated to accurately detect and rule out the haemodynamic significance of individual coronary artery stenoses.

Keywords

CT coronary angiography Fractional flow reserve (FFR) Non-invasive cardiac imaging Single photon emission computed tomography (SPECT) Positron emission tomography (PET) Myocardial perfusion imaging 

References

  1. 1.
    Pijls NH, Fearon WF, Tonino PA, et al. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention in patients with multivessel coronary artery disease: 2-year follow-up of the FAME (fractional flow reserve versus angiography for multivessel evaluation) study. J Am Coll Cardiol. 2010;56:177–84.PubMedCrossRefGoogle Scholar
  2. 2.
    Levine GN, Bates ER, Blankenship JC, et al. ACCF/AHA/SCAI guideline for percutaneous coronary intervention. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol. 2011;58:e44–e122.PubMedCrossRefGoogle Scholar
  3. 3.
    Wijns W, Kolh P, Danchin N, et al. Guidelines on myocardial revascularization. Eur Heart J. 2010;31:2501–55.PubMedCrossRefGoogle Scholar
  4. 4.
    Noto Jr TJ, Johnson LW, Krone R, et al. Cardiac catheterization 1990: a report of the Registry of the Society for Cardiac Angiography and Interventions (SCA&I). Catheter Cardiovasc Diagn. 1991;24:75–83.CrossRefGoogle Scholar
  5. 5.
    Patel MR, Peterson ED, Dai D, et al. Low diagnostic yield of elective coronary angiography. N Engl J Med. 2010;362:886–95.PubMedCrossRefGoogle Scholar
  6. 6.
    Meijs MF, Meijboom WB, Cramer MJ, et al. Computed tomography of the coronary arteries: an alternative? Scand Cardiovasc J. 2007;41:277–86.PubMedCrossRefGoogle Scholar
  7. 7.
    Budoff MJ, Dowe D, Jollis JG, et al. Diagnostic performance of 64-multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: results from the prospective multicenter ACCURACY (assessment by coronary computed tomographic angiography of individuals undergoing invasive coronary angiography) trial. J Am Coll Cardiol. 2008;52:1724–32.PubMedCrossRefGoogle Scholar
  8. 8.
    Meijboom WB, Meijs MF, Schuijf JD, et al. Diagnostic accuracy of 64-slice computed tomography coronary angiography: a prospective, multicenter, multivendor study. J Am Coll Cardiol. 2008;52:2135–44.PubMedCrossRefGoogle Scholar
  9. 9.
    Miller JM, Rochitte CE, Dewey M, et al. Diagnostic performance of coronary angiography by 64-row CT. N Engl J Med. 2008;359:2324–36.PubMedCrossRefGoogle Scholar
  10. 10.
    Weustink AC, de Feyter PJ. The role of multi-slice computed tomography in stable angina management: a current perspective. Neth Heart J. 2011;19:336–43.PubMedCrossRefGoogle Scholar
  11. 11.
    Taylor AJ, Cerqueira M, Hodgson JM, et al. ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 appropriate use criteria for cardiac computed tomography. A report of The American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the North American Society for Cardiovascular Imaging, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance. J Am Coll Cardiol. 2010;56:1864–94.PubMedCrossRefGoogle Scholar
  12. 12.
    Genders TS, Meijboom WB, Meijs MF, et al. CT coronary angiography in patients suspected of having coronary artery disease: decision making from various perspectives in the face of uncertainty. Radiology. 2009;253:734–44.PubMedCrossRefGoogle Scholar
  13. 13.
    Kato S, Kitagawa K, Ishida N, et al. Assessment of coronary artery disease using magnetic resonance coronary angiography: a national multicenter trial. J Am Coll Cardiol. 2010;56:983–91.PubMedCrossRefGoogle Scholar
  14. 14.
    Kim WY, Danias PG, Stuber M, et al. Coronary magnetic resonance angiography for the detection of coronary stenoses. N Engl J Med. 2001;345:1863–9.PubMedCrossRefGoogle Scholar
  15. 15.
    Beller GA, Heede RC. SPECT imaging for detecting coronary artery disease and determining prognosis by noninvasive assessment of myocardial perfusion and myocardial viability. J Cardiovasc Transl Res. 2011;4:416–24.PubMedCrossRefGoogle Scholar
  16. 16.
    Schindler TH, Schelbert HR, Quercioli A, et al. Cardiac PET imaging for the detection and monitoring of coronary artery disease and microvascular health. JACC Cardiovasc Imaging. 2010;3:623–40.PubMedCrossRefGoogle Scholar
  17. 17.
    Ishida N, Sakuma H, Motoyasu M, et al. Noninfarcted myocardium: correlation between dynamic first-pass contrast-enhanced myocardial MR imaging and quantitative coronary angiography. Radiology. 2003;229:209–16.PubMedCrossRefGoogle Scholar
  18. 18.
    Sakuma H, Suzawa N, Ichikawa Y, et al. Diagnostic accuracy of stress first-pass contrast-enhanced myocardial perfusion MRI compared with stress myocardial perfusion scintigraphy. AJR Am J Roentgenol. 2005;185:95–102.PubMedGoogle Scholar
  19. 19.
    Kitagawa K, Sakuma H, Nagata M, et al. Diagnostic accuracy of stress myocardial perfusion MRI and late gadolinium-enhanced MRI for detecting flow-limiting coronary artery disease: a multicenter study. Eur Radiol. 2008;18:2808–16.PubMedCrossRefGoogle Scholar
  20. 20.
    de Mello RA, Nacif MS, Dos Santos AA, et al. Diagnostic performance of combined cardiac MRI for detection of coronary artery disease. Eur J Radiol. 2011.Google Scholar
  21. 21.
    Beanlands RS, Youssef G. Diagnosis and prognosis of coronary artery disease: PET is superior to SPECT: Pro. J Nucl Cardiol. 2010;17:683–95.PubMedCrossRefGoogle Scholar
  22. 22.
    Klocke FJ, Baird MG, Lorell BH, et al. ACC/AHA/ASNC guidelines for the clinical use of cardiac radionuclide imaging–executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASNC Committee to Revise the 1995 Guidelines for the Clinical Use of Cardiac Radionuclide Imaging). Circulation. 2003;108:1404–18.PubMedCrossRefGoogle Scholar
  23. 23.
    Go RT, Marwick TH, MacIntyre WJ, et al. A prospective comparison of rubidium-82 PET and thallium-201 SPECT myocardial perfusion imaging utilizing a single dipyridamole stress in the diagnosis of coronary artery disease. J Nucl Med. 1990;31:1899–905.PubMedGoogle Scholar
  24. 24.
    Shaw LJ, Iskandrian AE. Prognostic value of gated myocardial perfusion SPECT. J Nucl Cardiol. 2004;11:171–85.PubMedCrossRefGoogle Scholar
  25. 25.
    Yoshinaga K, Chow BJ, Williams K, et al. What is the prognostic value of myocardial perfusion imaging using rubidium-82 positron emission tomography? J Am Coll Cardiol. 2006;48:1029–39.PubMedCrossRefGoogle Scholar
  26. 26.
    Dorbala S, Hachamovitch R, Curillova Z, et al. Incremental prognostic value of gated Rb-82 positron emission tomography myocardial perfusion imaging over clinical variables and rest LVEF. JACC Cardiovasc Imaging. 2009;2:846–54.PubMedCrossRefGoogle Scholar
  27. 27.
    Berman DS, Kang X, Slomka PJ, et al. Underestimation of extent of ischemia by gated SPECT myocardial perfusion imaging in patients with left main coronary artery disease. J Nucl Cardiol. 2007;14:521–8.PubMedCrossRefGoogle Scholar
  28. 28.
    Lima RS, Watson DD, Goode AR, et al. Incremental value of combined perfusion and function over perfusion alone by gated SPECT myocardial perfusion imaging for detection of severe three-vessel coronary artery disease. J Am Coll Cardiol. 2003;42:64–70.PubMedCrossRefGoogle Scholar
  29. 29.
    Parkash R, de Kemp RA, Ruddy TD, et al. Potential utility of rubidium 82 PET quantification in patients with 3-vessel coronary artery disease. J Nucl Cardiol. 2004;11:440–9.PubMedCrossRefGoogle Scholar
  30. 30.
    Kajander SA. Clinical value of absolute quantification of myocardial perfusion with (15)O-water in coronary artery disease. Circ Cardiovasc Imaging. 2011;4:678–84.PubMedCrossRefGoogle Scholar
  31. 31.
    Hajjiri MM, Leavitt MB, Zheng H, et al. Comparison of positron emission tomography measurement of adenosine-stimulated absolute myocardial blood flow versus relative myocardial tracer content for physiological assessment of coronary artery stenosis severity and location. JACC Cardiovasc Imaging. 2009;2:751–8.PubMedCrossRefGoogle Scholar
  32. 32.
    Dorbala S, Vangala D, Sampson U, et al. Value of vasodilator left ventricular ejection fraction reserve in evaluating the magnitude of myocardium at risk and the extent of angiographic coronary artery disease: a 82Rb PET/CT study. J Nucl Med. 2007;48:349–58.PubMedGoogle Scholar
  33. 33.
    Greenwood JP, Maredia N, Younger JF, et al. Cardiovascular magnetic resonance and single-photon emission computed tomography for diagnosis of coronary heart disease (CE-MARC): a prospective trial. Lancet. 2012;379:453–60.PubMedCrossRefGoogle Scholar
  34. 34.
    Paetsch I, Jahnke C, Wahl A, et al. Comparison of dobutamine stress magnetic resonance, adenosine stress magnetic resonance, and adenosine stress magnetic resonance perfusion. Circulation. 2004;110:835–42.PubMedCrossRefGoogle Scholar
  35. 35.
    Meijboom WB, van Mieghem CA, van Pelt N, et al. Comprehensive assessment of coronary artery stenoses: computed tomography coronary angiography versus conventional coronary angiography and correlation with fractional flow reserve in patients with stable angina. J Am Coll Cardiol. 2008;%19;52:636–43.Google Scholar
  36. 36.
    Koo BK, Erglis A, Doh JH, et al. Diagnosis of ischemia-causing coronary stenoses by noninvasive fractional flow reserve computed from coronary computed tomographic angiograms. Results from the prospective multicenter DISCOVER-FLOW (diagnosis of ischemia-causing stenoses obtained Via noninvasive fractional flow reserve) study. J Am Coll Cardiol. 2011;58:1989–97.PubMedCrossRefGoogle Scholar
  37. 37.
    Kajander S, Joutsiniemi E, Saraste M, et al. Cardiac positron emission tomography/computed tomography imaging accurately detects anatomically and functionally significant coronary artery disease. Circulation. 2010;122:603–13.PubMedCrossRefGoogle Scholar
  38. 38.
    Ragosta M, Bishop AH, Lipson LC, et al. Comparison between angiography and fractional flow reserve versus single-photon emission computed tomographic myocardial perfusion imaging for determining lesion significance in patients with multivessel coronary disease. Am J Cardiol. 2007;99:896–902.PubMedCrossRefGoogle Scholar
  39. 39.
    Forster S. Tc-99 m sestamibi single photon emission computed tomography for guiding percutaneous coronary intervention in patients with multivessel disease: a comparison with quantitative coronary angiography and fractional flow reserve. Int J Cardiovasc Imaging. 2010;26:203–13.PubMedCrossRefGoogle Scholar
  40. 40.
    Melikian N, De Bondt P, Tonino P, et al. Fractional flow reserve and myocardial perfusion imaging in patients with angiographic multivessel coronary artery disease. JACC Cardiovasc Interv. 2010;3:307–14.PubMedCrossRefGoogle Scholar
  41. 41.
    Kirschbaum SW, Springeling T, Rossi A, et al. Comparison of adenosine magnetic resonance perfusion imaging with invasive coronary flow reserve and fractional flow reserve in patients with suspected coronary artery disease. Int J Cardiol. 2011;147:184–6.PubMedCrossRefGoogle Scholar
  42. 42.
    Lockie T, Ishida M, Perera D, et al. High-resolution magnetic resonance myocardial perfusion imaging at 3.0-Tesla to detect hemodynamically significant coronary stenoses as determined by fractional flow reserve. J Am Coll Cardiol. 2011;57:70–5.PubMedCrossRefGoogle Scholar
  43. 43.
    Watkins S, Lyne J, Steedman T, et al. Validation of magnetic resonance myocardial perfusion imaging with fractional flow reserve for the detection of significant coronary heart disease. Circulation. 2009;120:2207–13.PubMedCrossRefGoogle Scholar
  44. 44.
    Bernhardt P, Walcher T, Rottbauer W, et al. Quantification of myocardial perfusion reserve at 1.5 and 3.0 Tesla: a comparison to fractional flow reserve. Int J Cardiovasc Imaging. 2012.Google Scholar
  45. 45.
    Korosoglou G, Elhmidi Y, Steen H, et al. Prognostic value of high-dose dobutamine stress magnetic resonance imaging in 1493 consecutive patients: assessment of myocardial wall motion and perfusion. J Am Coll Cardiol. 2010;56:1225–34.PubMedCrossRefGoogle Scholar
  46. 46.
    Sato A, Nozato T, Hikita H, et al. Incremental value of combining 64-slice computed tomography angiography with stress nuclear myocardial perfusion imaging to improve noninvasive detection of coronary artery disease. J Nucl Cardiol. 2010;17:19–26.PubMedCrossRefGoogle Scholar
  47. 47.
    Techasith T. Cury RC Stress myocardial CT perfusion: an update and future perspective. JACC Cardiovasc Imaging. 2011;4:905–16.PubMedCrossRefGoogle Scholar
  48. 48.
    Ko SM, Choi JW, Hwang HK, et al. Diagnostic performance of combined noninvasive anatomic and functional assessment with dual-source CT and adenosine-induced stress dual-energy CT for detection of significant coronary stenosis. AJR Am J Roentgenol. 2012;198:512–20.PubMedCrossRefGoogle Scholar
  49. 49.
    Rocha-Filho JA, Blankstein R, Shturman LD, et al. Incremental value of adenosine-induced stress myocardial perfusion imaging with dual-source CT at cardiac CT angiography. Radiology. 2010;254:410–9.PubMedCrossRefGoogle Scholar
  50. 50.
    Ko BS, Meredith IT, Leung M, et al. Computed tomography stress myocardial perfusion imaging in patients considered for revascularization: a comparison with fractional flow reserve. Eur Heart J. 2012;33:67–77.PubMedCrossRefGoogle Scholar
  51. 51.
    Bamberg F, Becker A, Schwarz F, et al. Detection of hemodynamically significant coronary artery stenosis: incremental diagnostic value of dynamic CT-based myocardial perfusion imaging. Radiology. 2011;260:689–98.Google Scholar
  52. 52.
    Choi JH, Min JK, Labounty TM, et al. Intracoronary transluminal attenuation gradient in coronary CT angiography for determining coronary artery stenosis. JACC Cardiovasc Imaging. 2011;4:1149–57.PubMedCrossRefGoogle Scholar
  53. 53.
    Kim HJ, Vignon-Clementel IE, Coogan JS, et al. Patient-specific modeling of blood flow and pressure in human coronary arteries. Ann Biomed Eng. 2010;38:3195–209.PubMedCrossRefGoogle Scholar
  54. 54.
    Uehara M, Takaoka H, Kobayashi Y, et al. Diagnostic accuracy of 320-slice computed-tomography for detection of significant coronary artery stenosis in patients with various heart rates and heart rhythms compared with conventional coronary-angiography. Int J Cardiol. 2012.Google Scholar
  55. 55.
    Leber AW, Johnson T, Becker A, et al. Diagnostic accuracy of dual-source multi-slice CT-coronary angiography in patients with an intermediate pretest likelihood for coronary artery disease. Eur Heart J. 2007;28:2354–60.PubMedCrossRefGoogle Scholar
  56. 56.
    Srichai MB, Lim RP, Donnino R, et al. Low-dose, prospective triggered high-pitch spiral coronary computed tomography angiography: comparison with retrospective spiral technique. Acad Radiol. 2012;19:554–61.PubMedCrossRefGoogle Scholar
  57. 57.
    Pijls NH, Sels JW. Functional measurement of coronary stenosis. J Am Coll Cardiol. 2012;59:1045–57.Google Scholar
  58. 58.
    Pijls NH, De Bruyne B, Peels K, et al. Measurement of fractional flow reserve to assess the functional severity of coronary-artery stenoses. N Engl J Med. 1996;334:1703–8.PubMedCrossRefGoogle Scholar
  59. 59.
    Pijls NH, van Schaardenburgh P, Manoharan G, et al. Percutaneous coronary intervention of functionally nonsignificant stenosis: 5-year follow-up of the DEFER study. J Am Coll Cardiol. 2007;49:2105–11.PubMedCrossRefGoogle Scholar
  60. 60.
    Zhou Y, Kassab GS, Molloi S. In vivo validation of the design rules of the coronary arteries and their application in the assessment of diffuse disease. Phys Med Biol. 2002;47:977–93.PubMedGoogle Scholar
  61. 61.
    Kamiya A, Togawa T. Adaptive regulation of wall shear stress to flow change in the canine carotid artery. Am J Physiol. 1980;239:H14–21.PubMedGoogle Scholar
  62. 62.
    Takx RA, Moscariello A, Schoepf UJ, et al. Quantification of left and right ventricular function and myocardial mass: comparison of low-radiation dose 2nd generation dual-source CT and cardiac MRI. Eur J Radiol. 2012;81:e598–604.PubMedCrossRefGoogle Scholar
  63. 63.
    Zarins CK, Zatina MA, Giddens DP, et al. Shear stress regulation of artery lumen diameter in experimental atherogenesis. J Vasc Surg. 1987;5:413–20.PubMedGoogle Scholar
  64. 64.
    Wilson RF, Wyche K, Christensen BV, et al. Effects of adenosine on human coronary arterial circulation. Circulation. 1990;82:1595–606.PubMedCrossRefGoogle Scholar
  65. 65.
    Di Carli MF, Murthy VL. Cardiac PET/CT for the evaluation of known or suspected coronary artery disease. Radiographics. 2011;31:1239–54.PubMedCrossRefGoogle Scholar
  66. 66.
    George RT, Arbab-Zadeh A, Miller JM, et al. Computed tomography myocardial perfusion imaging with 320-Row detector CT accurately detects myocardial ischemia in patients with obstructive coronary artery disease. Circ Cardiovasc Imaging. 2012;1:330–40.Google Scholar
  67. 67.
    Min JK, Berman DS, Budoff MJ, et al. Rationale and design of the DeFACTO (determination of fractional flow reserve by anatomic computed tomographic AngiOgraphy) study. J Cardiovasc Comput Tomogr. 2011;5:301–9.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Media / Bohn Stafleu van Loghum 2012

Authors and Affiliations

  • M. F. L. Meijs
    • 1
  • M. J. Cramer
    • 1
  • H. El Aidi
    • 1
  • P. A. Doevendans
    • 1
  1. 1.Department of CardiologyUniversity Medical Centre UtrechtUtrechtthe Netherlands

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