Looking to the Future: The Emerging Role of Fractal Analysis in Cardiac CT

Coronary computed tomography angiography (CTCA) is established as a first-line investigation for suspected coronary artery disease and is increasingly used for anatomical, functional, and structural cardiac assessment. Fractal analysis (FA) provides a framework for quantifying geometric and spatial complexity that is not captured by conventional measures of stenosis, plaque burden, or chamber geometry. Emerging cardiac CT studies have applied fractal dimension (FD), one quantitative measure derived from FA to coronary plaque, myocardial perfusion, and ventricular trabecular architecture. In coronary imaging, FD-based descriptors of plaque heterogeneity and boundary complexity have shown incremental diagnostic information beyond conventional plaque measures. In dynamic CT perfusion, fractal metrics quantify the spatial heterogeneity of myocardial enhancement and may help distinguish macrovascular from microvascular ischaemia. Cardiac CT studies have also demonstrated the feasibility of deriving ventricular trabecular FD and discriminating left ventricular non-compaction from other cardiomyopathies. This review synthesises the current evidence for FA in cardiac CT, evaluates methodological limitations and evidence maturity, and outlines priorities for standardisation, reproducibility, multimodal integration, and prospective clinical validation.