Korean J Radiol.  2020 Feb;21(2):192-202. 10.3348/kjr.2019.0230.

Coronary Computed Tomography Angiography-Derived Fractional Flow Reserve in Patients with Anomalous Origin of the Right Coronary Artery from the Left Coronary Sinus

Affiliations
  • 1Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, China. kevinzhlj@163.com
  • 2Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA.

Abstract


OBJECTIVE
To examine the fractional flow reserve derived from computed tomographic angiography (CT-FFR) in patients with anomalous origin of the right coronary artery from the left coronary sinus (R-ACAOS) with an interarterial course, assess the relationship of CT-FFR with the anatomical features of interarterial R-ACAOS on coronary computed tomographic angiography (CCTA), and determine its clinical relevance.
MATERIALS AND METHODS
Ninety-four patients with interarterial R-ACAOS undergoing CCTA were retrospectively included. Anatomic features (proximal vessel morphology [oval or slit-like], take-off angle, take-off level [below or above the pulmonary valve], take-off type, intramural course, % proximal narrowing area, length of narrowing, minimum luminal area [MLA] at systole and diastole, and vessel compression index) on CCTA associated with CT-FFR ≤ 0.80 were analyzed. Receiver operating characteristic analysis was performed to describe the diagnostic performance of CT-FFR ≤ 0.80 in detecting interarterial R-ACAOS.
RESULTS
Significant differences were found in proximal vessel morphology, take-off level, intramural course, % proximal narrowing area, and MLA at diastole (all p < 0.05) between the normal and abnormal CT-FFR groups. Take-off level, intramural course, and slit-like ostium (all p < 0.05) predicted hemodynamic abnormality (CT-FFR ≤ 0.80) with accuracies of 0.69, 0.71, and 0.81, respectively. Patients with CT-FFR ≤ 0.80 had a higher prevalence of typical angina (29.4% vs. 7.8%, p = 0.025) and atypical angina (29.4% vs. 6.5%, p = 0.016).
CONCLUSION
Take-off level, intramural course, and slit-like ostium were the main predictors of abnormal CT-FFR values. Importantly, patients with abnormal CT-FFR values showed a higher prevalence of typical angina and atypical angina, indicating that CT-FFR is a potential tool to gauge the clinical relevance in patients with interarterial R-ACAOS.

Keyword

Right coronary artery arising from the left coronary sinus; Computed tomographic angiography; Fractional flow reserve; Coronary vessel anomalies

MeSH Terms

Angiography
Coronary Sinus*
Coronary Vessel Anomalies
Coronary Vessels*
Diastole
Hemodynamics
Humans
Phenobarbital
Prevalence
Retrospective Studies
ROC Curve
Systole
Phenobarbital

Figure

  • Fig. 1 Representative cases of R-ACAOS with interarterial course R-ACAOS with interarterial course in 54-year-old man presenting with typical angina (A–D) and 49-year-old man without any complaint (E–G). A. Displays separate RCA ostia with acute take-off angle (arrow). Absence of adjacent epicardial fat in magnified view (arrowheads) suggests proximal intramural course of RCA. B. Shows take-off level of RCA above PV (line) in coronal view. C. Orthogonal cross-sectional image shows classic slit-like RCA proximal segment configuration (arrow). D. CT-FFR value of proximal RCA is 0.71, implying ischemia resulting from R-ACAOS with interarterial course. E, F. Show R-ACAOS with no intermural course, epicardial fat (arrow in E), and oval ostium in orthogonal cross-sections (arrow in F) with CT-FFR value of 0.98 (G). H. Shows location of CT-FFR measurement in R-ACAOS in our study; line 1 is located at RCA ostia, entrance of anomalous origin of RCA, while line 2 lies at exit, indicating lumen narrowing of proximal RCA from line 1 to line 2. CT-FFR values were measured at site of line 3, 1–2 cm distal to lumen narrowing segment of proximal RCA. I. Displays volume rendering image of R-ACAOS. AO = aorta, CT-FFR = FFR derived from computed tomographic angiography, FFR = fractional flow reserve, LAD = left anterior descending artery, PV = pulmonary valve, R-ACAOS = RCA from left coronary sinus, RCA = right coronary artery

  • Fig. 2 Multivariate analysis of anatomical features for predicting CT-FFR ≤ 0.80 in interarterial R-ACAOS patients. Model 1 shows full model with screened significant variables from univariate analysis. RCA take-off level above PV and slit-like proximal vessel morphology are found to be main predictors of abnormal CT-FFR values. Forward step-wise selection of model 2 was applied by using likelihood ratio test, which shows that besides RCA take-off level above PV and slit-like proximal vessel morphology, intramural course also contributes to CT-FFR ≤ 0.80 in R-ACAOS patients with interarterial course. CI = confidence interval, MLA = minimum luminal area

  • Fig. 3 AUCs for discrimination of CT-FFR ≤ 0.80 in R-ACAOS patients with interarterial course. Model 1: variable 1, take-off level (above PV); Model 2: variable 2, intramural course (present); Model 3: variable 3, proximal vessel morphology (slit-like); Model 4: variables 1 + 2; Model 5: variables 1 + 3; Model 6: variables 2 + 3; Model 7: variables 1 + 2 + 3. AUC = area under curve


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