Determinants of Rejection Rate for Coronary CT Angiography Fractional Flow Reserve Analysis

Background Coronary artery fractional flow reserve (FFR) derived from CT angiography (FFT CT ) enables functional assessment of coronary stenosis. Prior clinical trials showed 13%-33% of coronary CT angiography studies had insufficient quality for quantitative analysis with FFR CT. Purpose To determine the rejection rate of FFR CT analysis and to determine factors associated with technically unsuccessful calculation of FFR CT. Materials and Methods Prospectively acquired coronary CT angiography scans submitted as part of the Assessing Diagnostic Value of Noninvasive FFR CT in Coronary Care (ADVANCE) registry ( https://ClinicalTrials.gov : NCT02499679) and coronary CT angiography series submitted for clinical analysis were included. The primary outcome was the FFR CT rejection rate (defined as an inability to perform quantitative analysis with FFR CT ). Factors that were associated with FFR CT rejection rate were assessed with multiple linear regression. Results In the ADVANCE registry, FFR CT rejection rate due to inadequate image quality was 2.9% (80 of 2778 patients; 95% confidence interval [CI]: 2.1%, 3.2%). In the 10 621 consecutive patients who underwent clinical analysis, the FFR CT rejection rate was 8.4% ( n = 892; 95% CI: 6.2%, 7.2%; P < .001 vs the ADVANCE cohort). The main reason for the inability to perform FFR CT analysis was the presence of motion artifacts (63 of 80 [78%] and 729 of 892 [64%] in the ADVANCE and clinical cohorts, respectively). At multivariable analysis, section thickness in the ADVANCE (odds ratio [OR], 1.04; 95% CI: 1.001, 1.09; P = .045) and clinical (OR, 1.03; 95% CI: 1.02, 1.04; P < .001) cohorts and heart rate in the ADVANCE (OR, 1.05; 95% CI: 1.02, 1.08; P < .001) and clinical (OR, 1.06; 95% CI: 1.05, 1.07; P < .001) cohorts were independent predictors of rejection. Conclusion The rates for technically unsuccessful CT-derived fractional flow reserve in the ADVANCE registry and in a large clinical cohort were 2.9% and 8.4%, respectively. Thinner CT section thickness and lower patient heart rate may increase rates of completion of CT fractional flow reserve analysis. Published under a CC BY 4.0 license. Online supplemental material is available for this article. See also the editorial by Sakuma in this issue.