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冠状动脉CT血管成像的血流储备分数

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冠状动脉CT血管造影（coronary CT angiography, CCTA）是无创检查冠状动脉狭窄的高效手段，但并不能精准地反映具有临床意义的心肌缺血，基于CCTA结果的血运重建决策有可能造成不必要的资源浪费或血管再狭窄。

血流储备分数（Fractional Flow Reserve,FFR）是Pijls等在1993年首次提出的使用冠状动脉狭窄时对供血心肌区域提供最大血流量与同一区域正常供血情况下最大血流量之比来评价冠状动脉功能性狭窄的程度。虽FFR现今被作为诊断功能性狭窄的金标准，但同时兼具有创、操作复杂、患者耐受性差及费用高等推广局限性。

冠状动脉CT血管成像的血流储备分数(fractional flow reserve derived from CCTA ， FFRCT)是基于CTA的无创影像, 通过流体动力学技术计算3D血流模型，在最大充血状态下模拟冠脉血流流速、剪切力及模拟FFR，整个过程无介入、无射线、无造影剂、无禁忌证、无需影像科医生通过软件设备进行图像处理。

以下为以有创FFR为对照、以明确FFRCT诊断有效性为目的的研究基础:

2011年DISCOVER-FLOW研究“Diagnosis of ischemia-causing coronary stenoses by noninvasive fractional flow reserve computed from coronary computed tomographic angiograms. Results from the prospective multicenter DISCOVER-FLOW”在5家医院103例患者中比较FFRCT与有创FFR之间的相关性。

2012年DeFACTO研究“Diagnostic accuracy of fractional flow reserve from anatomic CT angiography”在17个中心252例患者中对407支血管中评价FFRCT+CCTA诊断冠脉狭窄的诊断价值。其中介绍了通过CT造影、FFRCT及冠脉造影三种手段还原的两例缺血病例的对比图象及FFRCT<0.80阈值，CT狭窄≥50%的敏感度及特异度分析。

2014年 NXT研究“Diagnostic performance of noninvasive fractional flow reserve derived from coronary computed tomography angiography in suspected coronary artery disease: the NXT trial (Analysis of Coronary Blood Flow Using CT Angiography: Next Steps)”采用计算模型对主要以中度狭窄（30~70%)为研究对象，比较了FFRCT与CCTA的敏感度和特异度。

2015年一项基于DISCOVER Flow 和DeFACTO研究数据的亚组分析结果显示，以有创FFR为参考依据，FFRCT在识别病变特异性缺血是时的诊断精度要高于管腔内对比度衰减梯度(transluminal attenuation gradient,TAG)、冠状动脉CT造影（coronary computed tomographic angiography）或两者结合所得出的结论，与有创FFR所测结果高度吻合，呈现了个体病例及在103例病变特异性缺血病例中获得的单项及多项指标结合后的敏感度、特异度分析结果。“Diagnostic performance of transluminal attenuation gradient and fractional flow reserve by coronary computed tomographic angiography (FFR(CT)) compared to invasive FFR: a sub-group analysis from the DISCOVER-FLOW and DeFACTO studies”。

2019年1月“Comparison of Coronary Computed Tomography Angiography, Fractional Flow Reserve, and Perfusion Imaging for Ischemia Diagnosis”使用PACIFIC研究数据在208例CAD患者中比较了FFRCT与CTA, SPECT,PET在血运动力学障碍中的诊断价值。尽管在综合比较后FFRCT的诊断准确度略高于冠脉CTA和SPECT, PET的诊断准确度要高于FFRCT。值得关注的是该研究设计仅对CTA、SPECT和PET设盲，而对FFRCT部分设盲，建议各位专家仅关注Intention-to-diagnose的结果。

拓展阅读

Pijls等首次提出采用FFR作为诊断冠脉功能性狭窄的测量指标： “Experimental basis of determining maximum coronary, myocardial, and collateral blood flow by pressure measurements for assessing functional stenosis severity before and after percutaneous transluminal coronary angioplasty”。

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冠状动脉CT血管成像的血流储备分数

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