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Discordance between Invasive and Non-Invasive Coronary Angiography: An In-Depth Functional and Anatomical Analysis
Shigetaka Kageyama1, Kaoru Tanaka2, Shinichiro Masuda1
1Department of Cardiology, National University of Ireland Galway, H91 TK33 Galway, Ireland.
Insights
This study highlights discrepancies between coronary computed tomography angiography (CCTA) and fractional flow reserve derived from CCTA (FFRCT) in complex coronary artery disease. Extensive calcification can lead to underestimation of stenosis severity by FFRCT.
Area of Science:
- Cardiovascular Imaging
- Interventional Cardiology
- Computational Fluid Dynamics
Background:
- Complex coronary artery disease (CAD) management requires accurate stenosis assessment.
- Coronary computed tomography angiography (CCTA) provides anatomical detail.
- Fractional flow reserve derived from CCTA (FFRCT) aims to assess functional significance.
Observation:
- A patient with complex CAD underwent revascularization guided by CCTA and FFRCT.
- CCTA indicated severe three-vessel disease (SYNTAX score 27).
- Initial FFRCT suggested only mild functional significance (SYNTAX score 2).
Findings:
- Discordance between CCTA and FFRCT prompted invasive angiography.
- Invasive fractional flow reserve (FFR) confirmed significant stenosis in the LAD.
- FFRCT analysis failed to detect significant LAD stenosis, likely due to extensive calcification.
Implications:
- Extensive arterial calcification poses a challenge for FFRCT accuracy.
- FFRCT may underestimate stenosis severity in heavily calcified lesions.
- Careful integration of anatomical and functional data is crucial for guiding CAD interventions.
Abstract:
A 79-year-old male with chronic coronary syndrome with complex coronary artery disease was included in the first-in-man trial of surgical revascularization guided solely by coronary computed tomography angiography (CCTA) and fractional flow reserve derived from CCTA (FFRCT). In CCTA analysis, the patient had calcified three-vessel disease, with a global anatomical SYNTAX score of 27. In contrast, in the initial FFRCT, only the ramus intermediate stenosis was physiologically significant, with no other vessels having an FFRCT ≤ 0.80 (functional SYNTAX score of 2). Discordance between the results of the CCTA and FFRCT necessitated an in-depth analysis by using both invasive and non-invasive coronary angiography. Angiography-derived fractional flow reserve (FFR) confirmed that the stenosis in the proximal left anterior descending artery (LAD) was physiologically significant, while it remained functionally negative in the second assessment of FFRCT. Extensive calcification is the most plausible explanation for the underestimation of the stenosis of proximal LAD in CCTA-derived FFR technology.
