• Dong Hyun Yang, Soo-Jin Kang, Hyun Jung Koo, Jihoon Kweon, Joon-Won Kang, Tae-Hwan Lim, Joonho Jung, Namkug Kim, June-Goo Lee, Seungbong Han, Jung-Min Ahn, Duk-Woo Park, Seung-Whan Lee, Cheol Whan Lee, Seong-Wook Park, Seung-Jung Park, Gary S Mintz, and Young-Hak Kim.
• Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
• JACC Cardiovasc Imaging. 2019 Apr 1; 12 (4): 707-717.

ObjectivesThis study examined the incremental value of subtended myocardial mass (Vsub) as assessed by coronary computed tomography angiography (CTA) for identifying lesion-specific ischemia verified by invasive fractional flow reserve (FFR) in quantitative coronary CTA.BackgroundFFR is determined not only by coronary stenosis severity, but also by Vsub. One-step evaluation of combined Vsub and coronary lesion morphology may improve the accuracy of coronary CTA for identifying ischemia-producing lesions.MethodsA total of 246 intermediate coronary artery lesions (30% to 80% diameter stenosis) in 220 patients (mean age 61.7 years, 168 men) interrogated by FFR were retrospectively studied. Coronary CTA data were used to assess the Vsub by coronary artery stenosis, minimal lumen area (MLA), percentage of aggregated plaque volume (%APV), positive remodeling, and low-attenuation plaque. The ability of Vsub/MLA2 to discriminate lesions with FFR ≤0.80 was examined. Diagnostic performance, odds ratios, and category-less net reclassification improvements of coronary CTA parameters for FFR-verified (≤0.80) ischemia were evaluated. On-site computed tomography (CT) derived-FFR (CT-FFR) and quantitative coronary angiography (QCA) data were also compared.ResultsOf 246 lesions, 84 (34.1%) showed an FFR ≤0.80. Vsub was independently associated with an FFR ≤0.80 (odds ratio: 1.04/1 cm3; p = 0.032) and showed incremental value over MLA. Vsub/MLA2 >4.16 was the best single parameter for discriminating an FFR ≤0.80 with 83.3% sensitivity and 67.9% specificity. The area under the curve (AUC) of Vsub/MLA2 >4.16 (0.80 [95% confidence interval: 0.75 to 0.85]) was better than that of MLA (change in [Δ]AUC: 0.069; p < 0.001), %APV (ΔAUC: 0.096; p = 0.017), and diameter stenosis of QCA (ΔAUC: 0.080; p = 0.037) and was comparable to that of CT-FFR (AUC 0.77; ΔAUC: 0.035; p = 0.304).ConclusionsVsub is an independent determinant of an FFR ≤0.80. The mathematical index of Vsub/MLA2 >4.16 assessed by coronary CTA shows better diagnostic performance for the detection of ischemia-producing lesions than CT-derived MLA alone or %APV and QCA parameters and was comparable to that of on-site CT-FFR.Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

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