The Accuracy of Virtual Fractional Flow Reserve From Invasive Angiography: Importance of the Method of Reconstructing Three-dimensional Coronary Artery Anatomy

Abstract Background Three dimensional (3D) coronary anatomy, reconstructed from coronary angiography (CA), is now being used as the basis to compute ‘virtual’ fractional flow reserve (vFFR), and thereby guide treatment decisions in patients with coronary artery disease (CAD). Reconstruction accuracy is therefore important. Yet these methods remain poorly validated. Furthermore, the magnitude of vFFR error arising from reconstruction is unkown. We aimed to validate a new method for 3D CA reconstruction and determine the effect this had upon the accuracy of vFFR.Methods Clinically realistic coronary phantom models were created (seven standard stenoses in aluminium and 15 patient-based 3D-printed) and imaged with CA, three times, according to clinical protocols, yielding 66 datasets. Each was reconstructed using epipolar line projection and intersection. All reconstructions were compared against the phantom models in terms of minimal lumen diameter, centreline and surface similarity. 3D-printed reconstructions (n=45) and the reference files from which they were printed underwent vFFR computation, and the results were compared. Results The average error in reconstructing minimum lumen diameter (MLD) was 0.05 (±0.03 mm) which was <1% (95%CI 0.13-1.61%) compared with caliper measurement. Overall surface similarity was excellent (Hausdorff distance 0.65 mm). Errors in 3D CA reconstruction accounted for an error in vFFR of ±0.06 (95% limits of agreement).Conclusions Errors arising from the epipolar line projection method used to reconstruct 3D coronary anatomy from CA are small but result in clinically relevant errors in vFFR simulation, amounting to approximately 40% of the total error associated with vFFR.