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This case explores the assessment of hemodynamic significance in a young athlete with a right coronary artery anomaly using both FFR and iFR.

April 23, 2026Open Access

An 11-Year-Old Athlete With Dynamic Stenosis of Coronary Artery Anomaly With Normal FFR-Dobutamine But Abnormal iFR-Dobutamine.

Key Points

This case explores the assessment of hemodynamic significance in a young athlete with a right coronary artery anomaly using both FFR and iFR.
Invasive angiography was performed to visualize the coronary arteries.
Intravascular ultrasound measured the cross-sectional area of the coronary lumen under resting and dobutamine stress conditions.
Both fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) assessments were conducted during dobutamine stress.
The intramural coronary lumen area decreased significantly from rest to dobutamine stress.
FFR during dobutamine was recorded at 0.85, while iFR was lower at 0.72, highlighting a disparity in ischemia assessment.
iFR measurements correlated more closely with the patient's symptoms and the geometric changes observed in the artery.

Abstract

Background Anomalous aortic origin of a right coronary artery (R-AAOCA) can cause stress-induced ischemia owing to dynamic stenosis of the intramural course. While fractional flow reserve during dobutamine challenge (FFRDobutamine) is the reference standard for hemodynamic assessment, specific scenarios favoring instantaneous wave-free ratio (iFR) over FFR remain unclear. Case Summary An 11-year-old male competitive basketball athlete with exertional angina and R-AAOCA underwent invasive angiography. Intravascular ultrasound showed a reduction in the intramural coronary lumen cross-sectional areafrom rest to dobutamine stress (from 4.6 to 3.1 mm2 in systole; from 7.6 to 3.7 mm2 in diastole), while FFRDobutamine was 0.85 and iFRDobutamine was 0.72. Discussion The patient's iFRDobutamine matched geometrical changes and clinical presentation, while his FFRDobutamine underestimated ischemia. Take-home Message In the case of predominant diastolic, stress-induced intramural deformation of the R-AAOCA vessel, iFRDobutamine-targeting diastolic stress-pressure ratio-may be preferred over FFRDobutamine, as the latter may miss ischemia given its cardiac cycle-averaged hyperemic calculations.

An 11-Year-Old Athlete With Dynamic Stenosis of Coronary Artery Anomaly With Normal FFR-Dobutamine But Abnormal iFR-Dobutamine.

Key Points

Abstract

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