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

• Tang CX
• Lu MJ
• Schoepf JU
• Tesche C
• Bauer M
• Nance J
• Griffith P
• Lu GM
• Zhang LJ

• KMID: 2471636
• DOI: http://doi.org/10.3348/kjr.2019.0230

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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