Diagnostic performance of quantitative, semi-quantitative, and visual analysis of dynamic CT myocardial perfusion imaging: a validation study with invasive fractional flow reserve

Objectives To investigate the diagnostic performance of absolute myocardial blood flow (MBF), MBF ratio , and visual analysis of dynamic CT myocardial perfusion imaging (CT-MPI) for the detection of hemodynamically significant coronary stenosis. Methods Consecutive patients with chest pain and intermediate-to-high pre-test probability of obstructive coronary artery disease were prospectively enrolled. All patients were referred for dynamic CT-MPI and fractional flow reserve (FFR) measurements within 4 weeks. Absolute MBF, MBF ratio (mean MBF of stenosis-subtended territories versus that of reference territories), and visually identified perfusion defect were tested for the diagnostic performance with reference to FFR. Results Sixty-two patients with 95 target vessels were included for final analysis. The mean radiation dose for dynamic CT-MPI was 3.0 (2.2–4.0) mSv. The mean lesion-based absolute MBF value was significantly lower in ischemic segments than that in non-ischemic segments (78.0 (65.0–86.0) mL/min/100 mL vs. 133.0 (117.5–163.8) mL/min/100 mL, p < 0.001). Similarly, the lesion-based MBF ratio was also markedly lower in territories with positive FFR results (0.52 (0.44–0.64) vs. 0.93 (0.91–0.97), p < 0.001). According to per-lesion ROC curve analysis, MBF and MBF ratio had a similar area under the curve (AUC) for detecting hemodynamically significant lesions (AUC = 0.942 vs. 0.956, p = 0.413), which were larger than that of visual analysis (AUC = 0.802, both p < 0.01). The vessel-based sensitivity, specificity, and diagnostic accuracy were 84.3%, 97.7%, and 90.5% for MBF and 96.1%, 93.2%, and 94.7% for MBF ratio . Conclusions Absolute MBF and MBF ratio had similarly excellent diagnostic performance with reference to FFR. In addition, these two parameters outperformed visual analysis for the detection of myocardial ischemia. Key Points • The mean MBF and MBF ratio were significantly lower in ischemic segments than those in non-ischemic segments. • Absolute MBF and MBF ratio had similar AUCs for the detection of hemodynamically significant lesions (AUC = 0.942 vs. 0.956, p = 0.413), which were larger than that of visual analysis (AUC = 0.802, both p < 0.01). • The vessel-based sensitivity, specificity, and diagnostic accuracy were 84.3%, 97.7%, and 90.5% for absolute MBF and 96.1%, 93.2%, and 94.7% for MBF ratio .