title: Classification of hemodynamically significant stenoses from dynamic CT perfusion and CTA myocardial territories.
abstract: OBJECTIVE
  Myocardial blood flow (MBF) obtained by dynamic CT perfusion (CTP) has been recently introduced to assess hemodynamic significance of coronary stenosis in coronary artery disease. The diagnostic performance of dynamic CTP MBF is limited due to subjective interpretation of MBF maps and MBF variations caused by physiological, methodological, and technical issues. In this paper, we introduce a novel method to quantify the hypoperfused volume (HPV) in myocardial territories derived from CT angiography (CTA) to overcome the limitations of current dynamic CTP MBF analysis methods.
  
  
  METHODS
  The diagnostic performance of HPV in classifying significant stenoses was evaluated on 22 patients (57 vessels) that underwent CTA, CTP and invasive fractional flow reserve (FFR). FFR was used as the standard of reference to determine stenosis significance. The diagnostic performance was compared to that of the mean MBF computed in regions manually annotated by an expert (MA-MBF). HPV was derived by thresholding the MBF in myocardial territories constructed from CTA by locating the closest artery. Diagnostic performance was evaluated using leave-one-case out cross-validation. Inter-observer reproducibility was assessed by performing annotations of coronary seeds (HPV) and manual regions (MA-MBF) with two users. In addition, the influence of different parameter settings on the diagnostic performance of HPV was assessed.
  
  
  RESULTS
  Leave-one-case out cross-validation showed that HPV has an accuracy of 72% (58-83%) with sensitivity of 72% (47-90%) and specificity of 72% (58-83%). The accuracy of MA-MBF was 70% (57-82%) with a sensitivity of 50% (26-74%) and a specificity of 79% (64-91%). The Spearman correlation and the kappa statistic was (ρ = 0.94, κ = 0.86) for HPV and (ρ = 0.72, κ = 0.82) for MA-MBF. The influence of parameter settings on HPV based diagnostic performance was not significant.
  
  
  CONCLUSIONS
  The proposed HPV accurately classifies hemodynamically significant stenoses with a level of accuracy comparable to the mean MBF in regions annotated by an expert. HPV improves inter-observer reproducibility as compared to MA-MBF by providing a more objective criterion to associate the stenotic coronary with the supplied myocardial territory.
authors.affiliation: Department of Imaging Physics, TU Delft, 2628CJ, Delft, The Netherlands.|Biomedical Imaging Group Rotterdam, Department of Radiology & Nuclear Medicine and Department of Medical Informatics, Erasmus MC, University Medical Center Rotterdam's, 3015 CE, Rotterdam, The Netherlands.
authors.forename: Marco
authors.initials: M
authors.lastname: Giordano
authors.affiliation: Department of Imaging Physics, TU Delft, 2628CJ, Delft, The Netherlands.|Biomedical Imaging Group Rotterdam, Department of Radiology & Nuclear Medicine and Department of Medical Informatics, Erasmus MC, University Medical Center Rotterdam's, 3015 CE, Rotterdam, The Netherlands.
authors.forename: Dirk H J
authors.initials: DH
authors.lastname: Poot
authors.affiliation: Department of Radiology and Cardiology, Erasmus MC, University Medical Center Rotterdam's, 3015CE, Rotterdam, The Netherlands.
authors.forename: Adriaan
authors.initials: A
authors.lastname: Coenen
authors.affiliation: Biomedical Imaging Group Rotterdam, Department of Radiology & Nuclear Medicine and Department of Medical Informatics, Erasmus MC, University Medical Center Rotterdam's, 3015 CE, Rotterdam, The Netherlands.
authors.forename: Theo
authors.initials: T
authors.lastname: van Walsum
authors.affiliation: Istituto di Radiologia, Universitá di Verona, Policlinico G.B. Rossi, P.le L.A., 37134, Verona, Italy.
authors.forename: Michela
authors.initials: M
authors.lastname: Tezza
authors.affiliation: Department of Radiology and Cardiology, Erasmus MC, University Medical Center Rotterdam's, 3015CE, Rotterdam, The Netherlands.
authors.forename: Koen
authors.initials: K
authors.lastname: Nieman
authors.affiliation: Department of Imaging Physics, TU Delft, 2628CJ, Delft, The Netherlands.|Biomedical Imaging Group Rotterdam, Department of Radiology & Nuclear Medicine and Department of Medical Informatics, Erasmus MC, University Medical Center Rotterdam's, 3015 CE, Rotterdam, The Netherlands.
authors.forename: Wiro J
authors.initials: WJ
authors.lastname: Niessen
mesh_terms: D000072226:Computed Tomography Angiography; D023921:Coronary Stenosis / Q000000981:diagnostic imaging* / Q000503:physiopathology*; D006439:Hemodynamics; D006801:Humans; D007091:Image Processing, Computer-Assisted / Q000379:methods*; D055414:Myocardial Perfusion Imaging; D015203:Reproducibility of Results; D059629:Signal-To-Noise Ratio
keywords: Myocardial blood flow; coronary CTA; coronary stenosis; dynamic CT perfusion; fractional flow reserve