CT derived fractional flow reserve: Part 2 - Critical appraisal of the literature

Patricia F Rodriguez-Lozano; Anam Waheed; Sotirios Evangelou; Márton Kolossváry; Kashif Shaikh; Saira Siddiqui; Lauren Stipp; Suvasini Lakshmanan; En-Haw Wu; Nick S Nurmohamed; Ady Orbach; Vinit Baliyan; Joao Francisco Ribeiro Gavina de Matos; Siddharth J Trivedi; Nidhi Madan; Todd C Villines; Abdul Rahman Ihdayhid; SCCT FiRST (Fellow and Resident Leaders of SCCT) Committee

doi:10.1016/j.jcct.2025.05.241

CT derived fractional flow reserve: Part 2 - Critical appraisal of the literature

J Cardiovasc Comput Tomogr. 2025 Jul-Aug;19(4):397-408. doi: 10.1016/j.jcct.2025.05.241. Epub 2025 Jun 13.

Authors

Patricia F Rodriguez-Lozano¹, Anam Waheed², Sotirios Evangelou³, Márton Kolossváry⁴, Kashif Shaikh⁵, Saira Siddiqui⁶, Lauren Stipp⁷, Suvasini Lakshmanan⁸, En-Haw Wu⁹, Nick S Nurmohamed¹⁰, Ady Orbach¹¹, Vinit Baliyan¹², Joao Francisco Ribeiro Gavina de Matos¹³, Siddharth J Trivedi¹⁴, Nidhi Madan¹⁵, Todd C Villines¹⁶, Abdul Rahman Ihdayhid¹⁷; SCCT FiRST (Fellow and Resident Leaders of SCCT) Committee

Affiliations

¹ Department of Medicine, Cardiovascular Division, University of Virginia Health, Charlottesville, VA, USA; Department of Radiology and Medical Imaging, University of Virginia Health, Charlottesville, VA, USA.
² Medstar Heart and Vascular Center, Washington Hospital Center, Georgetown University Hospital, Washington, DC, USA.
³ Department of Cardiology, European Interbalkan Medical Center, Thessaloniki, Greece.
⁴ Gottsegen National Cardiovascular Center, Budapest, Hungary; Physiological Controls Research Center, University Research and Innovation Center, Óbuda University, Budapest, Hungary.
⁵ Department of Medicine, Division of Cardiology, University of Tennessee, Knoxville, TN, USA.
⁶ Department of Pediatrics, Morristown Medical Center, Morristown, NJ, USA; Department of Pediatrics, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA.
⁷ Department of Cardiology, Ascension Sacred Heart Emerald Coast, Miramar Beach, FL, USA.
⁸ Department of Cardiology, Lundquist Institute of Biomedical Innovation and Research, Los Angeles, CA, USA.
⁹ Department of Diagnostic Radiology, Oregon Health and Science University, OR, USA.
¹⁰ Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Division of Cardiology, The George Washington University School of Medicine, Washington, DC, USA.
¹¹ Department of Cardiology, Edith Wolfson Medical Center, Holon, Israel.
¹² Department of Radiology, Division of Cardiovascular Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
¹³ Department of Medical Imaging Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, ON, Canada.
¹⁴ Cardiovascular Imaging Program, Department of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
¹⁵ UnityPoint Health St Luke's Hospital, Cedar Rapids, IA, USA.
¹⁶ Department of Medicine, Cardiovascular Division, University of Virginia Health, Charlottesville, VA, USA.
¹⁷ Department of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia; Curtin Medical School, Curtin University, Perth, Western Australia, Australia. Electronic address: abdul.ihdayhid@perkins.org.au.

PMID: 40514256
DOI: 10.1016/j.jcct.2025.05.241

Abstract

The integration of computed tomography-derived fractional flow reserve (CT-FFR), utilizing computational fluid dynamics and artificial intelligence (AI) in routine coronary computed tomographic angiography (CCTA), presents a promising approach to enhance evaluations of functional lesion severity. Extensive evidence underscores the diagnostic accuracy, prognostic significance, and clinical relevance of CT-FFR, prompting recent clinical guidelines to recommend its combined use with CCTA for selected individuals with with intermediate stenosis on CCTA and stable or acute chest pain. This manuscript critically examines the existing clinical evidence, evaluates the diagnostic performance, and outlines future perspectives for integrating noninvasive assessments of coronary anatomy and physiology. Furthermore, it serves as a practical guide for medical imaging professionals by addressing common pitfalls and challenges associated with CT-FFR while proposing potential solutions to facilitate its successful implementation in clinical practice.

Keywords: Computational fractional flow reserve; Coronary artery disease; Coronary computed tomography angiography.

Publication types

Review

MeSH terms

Artificial Intelligence
Computed Tomography Angiography*
Coronary Angiography* / methods
Coronary Artery Disease* / diagnostic imaging
Coronary Artery Disease* / physiopathology
Coronary Stenosis* / diagnostic imaging
Coronary Stenosis* / physiopathology
Coronary Vessels* / diagnostic imaging
Coronary Vessels* / physiopathology
Fractional Flow Reserve, Myocardial*
Humans
Models, Cardiovascular
Predictive Value of Tests
Prognosis
Radiographic Image Interpretation, Computer-Assisted*
Reproducibility of Results
Severity of Illness Index

Grants and funding

K01 HL174889/HL/NHLBI NIH HHS/United States