Anatomically High-Risk Features, Functionally Benign: CT-FFR–Guided Assessment of Coronary Artery Anomalies: case report

Abstract Background Anomalous aortic origin of a coronary artery (AAOCA) can show anatomically high-risk features on coronary CT angiography (CCTA), yet ischemia may be dynamic and not proportional to anatomic appearance. CT-derived fractional flow reserve (CT-FFR) provides lesion-specific physiologic information from routine CCTA datasets and may aid management when anatomy and symptoms are discordant. Case summary We describe three adults evaluated with CCTA and adjunct CT-FFR (DeepVessel FFR). Case 1: a 61-year-old asymptomatic man with anomalous right coronary artery (RCA) origin from the left coronary sinus and an interarterial course; CT-FFR 0.94–0.95 and normal myocardial perfusion scintigraphy supported conservative management. Case 2: a 23-year-old woman with intermittent, non-exertional chest discomfort and family history of sudden cardiac death; CCTA showed a rare left main coronary artery (LMCA) origin from the non-coronary sinus with a retroaortic course; CT-FFR remained >0.80 (LAD 0.87; LCX 0.88) and IVUS excluded LM ostial stenosis (MLA 11 mm2). Case 3: a 50-year-old asymptomatic man with anomalous RCA from the left coronary sinus and an interarterial course; CT-FFR nadir was 0.87, and Heart Team discussion supported conservative management. Follow-up (6–12 months) was uneventful. Discussion CT-FFR may complement anatomic assessment in selected adults with AAOCA and help avoid unnecessary invasive testing. However, because CT-FFR is derived from resting CCTA it cannot exclude exertion-dependent dynamic compression; persistent concern should prompt stress testing and/or invasive physiologic and intravascular assessment.