Vol 28, No 1 (2021)
Original Article
Published online: 2019-03-14

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Coronary artery height differences and their effect on fractional flow reserve

Firas Al-Janabi12, Grigoris Karamasis12, Chritopher M. Cook3, Alamgir M. Kabir1, Rohan O. Jagathesan1, Nicholas M. Robinson1, Jeremy W. Sayer1, Rajesh K. Aggarwal1, Gerald J. Clesham12, Paul R. Kelly1, Reto A. Gamma1, Kare H. Tang1, Thomas R. Keeble12, John R. Davies12
Pubmed: 30912578
Cardiol J 2021;28(1):41-48.


Background: Fractional flow reserve (FFR) uses pressure-based measurements to assess the severity
of a coronary stenosis. Distal pressure (Pd) is often at a different vertical height to that of the proximal
aortic pressure (Pa). The difference in pressure between Pd and Pa due to hydrostatic pressure, may
impact FFR calculation.

Methods: One hundred computed tomography coronary angiographies were used to measure height
differences between the coronary ostia and points in the coronary tree. Mean heights were used to calculate the hydrostatic pressure effect in each artery, using a correction factor of 0.8 mmHg/cm. This
was tested in a simulation of intermediate coronary stenosis to give the “corrected FFR” (cFFR) and
percentage of values, which crossed a threshold of 0.8.

Results: The mean height from coronary ostium to distal left anterior descending (LAD) was +5.26 cm,
distal circumflex (Cx) –3.35 cm, distal right coronary artery-posterior left ventricular artery (RCA-PLV)
–5.74 cm and distal RCA-posterior descending artery (PDA) +1.83 cm. For LAD, correction resulted in a mean change in FFR of +0.042, –0.027 in the Cx, –0.046 in the PLV and +0.015 in the PDA. Using 200 random FFR values between 0.75 and 0.85, the resulting cFFR crossed the clinical treatment
threshold of 0.8 in 43% of LAD, 27% of Cx, 47% of PLV and 15% of PDA cases.

Conclusions: There are significant vertical height differences between the distal artery (Pd) and its point of normalization (Pa). This is likely to have a modest effect on FFR, and correcting for this results in a proportion of values crossing treatment thresholds. Operators should be mindful of this phenomenon when interpreting FFR values.

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