Imaging-Derived Coronary Fractional Flow Reserve: Advances in Physics-Based, Machine-Learning, and Physics-Informed Methods

Purpose of Review Imaging derived fractional flow reserve (FFR) is rapidly evolving beyond conventional computational fluid dynamics (CFD) based pipelines toward machine learning (ML), deep learning (DL), and physics informed approaches that enable fast, wire free, and scalable functional assessment of coronary stenosis. This review synthesizes recent advances in CT and angiography based FFR, with particular emphasis on emerging physics informed neural networks and neural operators (PINNs and PINOs) and key considerations for their clinical translation. Recent Findings ML/DL approaches have markedly improved automation and computational speed, enabling prediction of pressure and FFR from anatomical descriptors or angiographic contrast dynamics. However, their real-world performance and generalizability can remain variable and sensitive to domain shift, due to multi-center heterogeneity, interpretability challenges, and differences in acquisition protocols and image quality. Physics informed learning introduces conservation structure and boundary condition consistency into model training, improving generalizability and reducing dependence on dense supervision while maintaining rapid inference. Recent evaluation trends increasingly highlight deployment oriented metrics, including calibration, uncertainty quantification, and quality control gatekeeping, as essential for safe clinical use. Summary The field is converging toward imaging derived FFR methods that are faster, more automated, and more reliable. While ML/DL offers substantial efficiency gains, physics informed frameworks such as PINNs and PINOs may provide a more robust balance between speed and physical consistency. Prospective multi center validation and standardized evaluation will be critical to support broad and safe clinical adoption.