1
|
Villegas-Martinez M, de Villedon de Naide V, Muthurangu V, Bustin A. The beating heart: artificial intelligence for cardiovascular application in the clinic. MAGMA (NEW YORK, N.Y.) 2024:10.1007/s10334-024-01180-9. [PMID: 38907767 DOI: 10.1007/s10334-024-01180-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 04/25/2024] [Accepted: 06/13/2024] [Indexed: 06/24/2024]
Abstract
Artificial intelligence (AI) integration in cardiac magnetic resonance imaging presents new and exciting avenues for advancing patient care, automating post-processing tasks, and enhancing diagnostic precision and outcomes. The use of AI significantly streamlines the examination workflow through the reduction of acquisition and postprocessing durations, coupled with the automation of scan planning and acquisition parameters selection. This has led to a notable improvement in examination workflow efficiency, a reduction in operator variability, and an enhancement in overall image quality. Importantly, AI unlocks new possibilities to achieve spatial resolutions that were previously unattainable in patients. Furthermore, the potential for low-dose and contrast-agent-free imaging represents a stride toward safer and more patient-friendly diagnostic procedures. Beyond these benefits, AI facilitates precise risk stratification and prognosis evaluation by adeptly analysing extensive datasets. This comprehensive review article explores recent applications of AI in the realm of cardiac magnetic resonance imaging, offering insights into its transformative potential in the field.
Collapse
Affiliation(s)
- Manuel Villegas-Martinez
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Hôpital Xavier Arnozan, Université de Bordeaux-INSERM U1045, Avenue du Haut Lévêque, 33604, Pessac, France
- Department of Cardiovascular Imaging, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Avenue de Magellan, 33604, Pessac, France
| | - Victor de Villedon de Naide
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Hôpital Xavier Arnozan, Université de Bordeaux-INSERM U1045, Avenue du Haut Lévêque, 33604, Pessac, France
- Department of Cardiovascular Imaging, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Avenue de Magellan, 33604, Pessac, France
| | - Vivek Muthurangu
- Center for Cardiovascular Imaging, UCL Institute of Cardiovascular Science, University College London, London, WC1N 1EH, UK
| | - Aurélien Bustin
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Hôpital Xavier Arnozan, Université de Bordeaux-INSERM U1045, Avenue du Haut Lévêque, 33604, Pessac, France.
- Department of Cardiovascular Imaging, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Avenue de Magellan, 33604, Pessac, France.
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
| |
Collapse
|
2
|
Guo RX, Tian X, Bazoukis G, Tse G, Hong S, Chen KY, Liu T. Application of artificial intelligence in the diagnosis and treatment of cardiac arrhythmia. Pacing Clin Electrophysiol 2024; 47:789-801. [PMID: 38712484 DOI: 10.1111/pace.14995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 03/29/2024] [Accepted: 04/18/2024] [Indexed: 05/08/2024]
Abstract
The rapid growth in computational power, sensor technology, and wearable devices has provided a solid foundation for all aspects of cardiac arrhythmia care. Artificial intelligence (AI) has been instrumental in bringing about significant changes in the prevention, risk assessment, diagnosis, and treatment of arrhythmia. This review examines the current state of AI in the diagnosis and treatment of atrial fibrillation, supraventricular arrhythmia, ventricular arrhythmia, hereditary channelopathies, and cardiac pacing. Furthermore, ChatGPT, which has gained attention recently, is addressed in this paper along with its potential applications in the field of arrhythmia. Additionally, the accuracy of arrhythmia diagnosis can be improved by identifying electrode misplacement or erroneous swapping of electrode position using AI. Remote monitoring has expanded greatly due to the emergence of contactless monitoring technology as wearable devices continue to develop and flourish. Parallel advances in AI computing power, ChatGPT, availability of large data sets, and more have greatly expanded applications in arrhythmia diagnosis, risk assessment, and treatment. More precise algorithms based on big data, personalized risk assessment, telemedicine and mobile health, smart hardware and wearables, and the exploration of rare or complex types of arrhythmia are the future direction.
Collapse
Affiliation(s)
- Rong-Xin Guo
- Tianjin Key Laboratory of lonic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Xu Tian
- Tianjin Key Laboratory of lonic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - George Bazoukis
- Department of Cardiology, Larnaca General Hospital, Inomenon Polition Amerikis, Larnaca, Cyprus
- Department of Basic and Clinical Sciences, University of Nicosia Medical School, Nicosia, Cyprus
| | - Gary Tse
- Tianjin Key Laboratory of lonic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
- Cardiovascular Analytics Group, PowerHealth Research Institute, Hong Kong, China
- School of Nursing and Health Studies, Hong Kong Metropolitan University, Hong Kong, China
| | - Shenda Hong
- National Institute of Health Data Science, Peking University, Beijing, China
- Institute of Medical Technology, Peking University Health Science Center, Beijing, China
| | - Kang-Yin Chen
- Tianjin Key Laboratory of lonic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Tong Liu
- Tianjin Key Laboratory of lonic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| |
Collapse
|
3
|
Riaz Gondal MU, Atta Mehdi H, Khenhrani RR, Kumari N, Ali MF, Kumar S, Faraz M, Malik J. Role of Machine Learning and Artificial Intelligence in Arrhythmias and Electrophysiology. Cardiol Rev 2024:00045415-990000000-00270. [PMID: 38761137 DOI: 10.1097/crd.0000000000000715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/20/2024]
Abstract
Machine learning (ML), a subset of artificial intelligence (AI) centered on machines learning from extensive datasets, stands at the forefront of a technological revolution shaping various facets of society. Cardiovascular medicine has emerged as a key domain for ML applications, with considerable efforts to integrate these innovations into routine clinical practice. Within cardiac electrophysiology, ML applications, especially in the automated interpretation of electrocardiograms, have garnered substantial attention in existing literature. However, less recognized are the diverse applications of ML in cardiac electrophysiology and arrhythmias, spanning basic science research on arrhythmia mechanisms, both experimental and computational, as well as contributions to enhanced techniques for mapping cardiac electrical function and translational research related to arrhythmia management. This comprehensive review delves into various ML applications within the scope of this journal, organized into 3 parts. The first section provides a fundamental understanding of general ML principles and methodologies, serving as a foundational resource for readers interested in exploring ML applications in arrhythmia research. The second part offers an in-depth review of studies in arrhythmia and electrophysiology that leverage ML methodologies, showcasing the broad potential of ML approaches. Each subject is thoroughly outlined, accompanied by a review of notable ML research advancements. Finally, the review delves into the primary challenges and future perspectives surrounding ML-driven cardiac electrophysiology and arrhythmias research.
Collapse
Affiliation(s)
| | - Hassan Atta Mehdi
- Department of Medicine, Jinnah Postgraduate Medical Centre, Karachi, Pakistan
| | - Raja Ram Khenhrani
- Department of Medicine, Internal Medicine Fellow, Shaheed Mohtarma Benazir Bhutto Medical College and Lyari General Hospital, Karachi, Pakistan
| | - Neha Kumari
- Department of Medicine, Jinnah Postgraduate Medical Centre, Karachi, Pakistan
| | - Muhammad Faizan Ali
- Department of Medicine, Jinnah Postgraduate Medical Centre, Karachi, Pakistan
| | - Sooraj Kumar
- Department of Medicine, Jinnah Sindh Medical University, Karachi, Pakistan; and
| | - Maria Faraz
- Department of Cardiovascular Medicine, Cardiovascular Analytics Group, Rawalpindi, Pakistan
| | - Jahanzeb Malik
- Department of Cardiovascular Medicine, Cardiovascular Analytics Group, Rawalpindi, Pakistan
| |
Collapse
|
4
|
Crean AM. Scanning the Imaging Horizon for Hypertrophic Cardiomyopathy. Can J Cardiol 2024; 40:899-906. [PMID: 38467329 DOI: 10.1016/j.cjca.2024.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 02/27/2024] [Accepted: 02/27/2024] [Indexed: 03/13/2024] Open
Abstract
In this article some of the recent advances in the use of noninvasive imaging applied to patients with hypertrophic cardiomyopathy (HCM) are discussed. Echocardiography and cardiac computed tomography are briefly discussed with respect to their power to detect apical aneurysmal disease. Echocardiographic phenotype-genotype correlations and the use of echocardiography to characterize myocardial work are reviewed. Positron emission tomography is reviewed in the context of ischemia imaging and also in the context of the use of a new tracer that might allow for recognition of early activation of the fibrosis pathway. Next, the technical capabilities of cardiovascular magnetic resonance to measure myocardial perfusion, oxygenation, and disarray are discussed as they apply to HCM. The application of radiomics to improve prediction of sudden cardiac death is touched upon. Finally, a deep learning approach to the recognition of HCM vs phenocopies is presented as a potential future diagnostic aid in the not-too-distant future.
Collapse
Affiliation(s)
- Andrew M Crean
- Manchester Heart Center, University of Manchester, Manchester, United Kingdom; Division of Cardiology, Ottawa Heart Institute, Ottawa, Ontario, Canada.
| |
Collapse
|
5
|
Holmstrom L, Chugh H, Nakamura K, Bhanji Z, Seifer M, Uy-Evanado A, Reinier K, Ouyang D, Chugh SS. An ECG-based artificial intelligence model for assessment of sudden cardiac death risk. COMMUNICATIONS MEDICINE 2024; 4:17. [PMID: 38413711 PMCID: PMC10899257 DOI: 10.1038/s43856-024-00451-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 02/02/2024] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND Conventional ECG-based algorithms could contribute to sudden cardiac death (SCD) risk stratification but demonstrate moderate predictive capabilities. Deep learning (DL) models use the entire digital signal and could potentially improve predictive power. We aimed to train and validate a 12 lead ECG-based DL algorithm for SCD risk assessment. METHODS Out-of-hospital SCD cases were prospectively ascertained in the Portland, Oregon, metro area. A total of 1,827 pre- cardiac arrest 12 lead ECGs from 1,796 SCD cases were retrospectively collected and analyzed to develop an ECG-based DL model. External validation was performed in 714 ECGs from 714 SCD cases from Ventura County, CA. Two separate control group samples were obtained from 1342 ECGs taken from 1325 individuals of which at least 50% had established coronary artery disease. The DL model was compared with a previously validated conventional 6 variable ECG risk model. RESULTS The DL model achieves an AUROC of 0.889 (95% CI 0.861-0.917) for the detection of SCD cases vs. controls in the internal held-out test dataset, and is successfully validated in external SCD cases with an AUROC of 0.820 (0.794-0.847). The DL model performs significantly better than the conventional ECG model that achieves an AUROC of 0.712 (0.668-0.756) in the internal and 0.743 (0.711-0.775) in the external cohort. CONCLUSIONS An ECG-based DL model distinguishes SCD cases from controls with improved accuracy and performs better than a conventional ECG risk model. Further detailed investigation is warranted to evaluate how the DL model could contribute to improved SCD risk stratification.
Collapse
Affiliation(s)
- Lauri Holmstrom
- Center for Cardiac Arrest Prevention, Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Harpriya Chugh
- Center for Cardiac Arrest Prevention, Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Kotoka Nakamura
- Center for Cardiac Arrest Prevention, Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ziana Bhanji
- Center for Cardiac Arrest Prevention, Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Madison Seifer
- Center for Cardiac Arrest Prevention, Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Audrey Uy-Evanado
- Center for Cardiac Arrest Prevention, Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Kyndaron Reinier
- Center for Cardiac Arrest Prevention, Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - David Ouyang
- Center for Cardiac Arrest Prevention, Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Division of Artificial Intelligence in Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Sumeet S Chugh
- Center for Cardiac Arrest Prevention, Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
- Division of Artificial Intelligence in Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| |
Collapse
|
6
|
Sani MM, Sung E, Engels M, Daimee UA, Trayanova N, Wu KC, Chrispin J. Association of epicardial and intramyocardial fat with ventricular arrhythmias. Heart Rhythm 2023; 20:1699-1705. [PMID: 37640127 PMCID: PMC10881203 DOI: 10.1016/j.hrthm.2023.08.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 08/16/2023] [Accepted: 08/22/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Among patients with ischemic cardiomyopathy (ICM) and nonischemic cardiomyopathy (NICM), myocardial fibrosis is associated with an increased risk for ventricular arrhythmia (VA). Growing evidence suggests that myocardial fat contributes to ventricular arrhythmogenesis. However, little is known about the volume and distribution of epicardial adipose tissue and intramyocardial fat and their relationship with VAs. OBJECTIVE The purpose of this study was to assess the association of contrast-enhanced computed tomography (CE-CT)-derived left ventricular (LV) tissue heterogeneity, epicardial adipose tissue volume, and intramyocardial fat volume with the risk of VA in ICM and NICM patients. METHODS Patients enrolled in the PROSE-ICD registry who underwent CE-CT were included. Intramyocardial fat volume (voxels between -180 and -5 Hounsfield units [HU]), epicardial adipose tissue volume (between -200 and -50 HU), and LV tissue heterogeneity were calculated. The primary endpoint was appropriate ICD shocks or sudden arrhythmic death. RESULTS Among 98 patients (47 ICM, 51 NICM), LV tissue heterogeneity was associated with VA (odds ratio [OR] 1.10; P = .01), particularly in the ICM cohort. In the NICM subgroup, epicardial adipose tissue and intramyocardial fat volume were associated with VA (OR 1.11, P = .01; and OR = 1.21, P = .01, respectively) but not in the ICM patients (OR 0.92, P =.22; and OR = 0.96, P =.19, respectively). CONCLUSION In ICM patients, increased fat distribution heterogeneity is associated with VA. In NICM patients, an increased volume of intramyocardial fat and epicardial adipose tissue is associated with a higher risk for VA. Our findings suggest that fat's contribution to VAs depends on the underlying substrate.
Collapse
Affiliation(s)
- Maryam Mojarrad Sani
- Department of Medicine, Division of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Eric Sung
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland
| | - Marc Engels
- Department of Medicine, Division of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Usama A Daimee
- Department of Medicine, Division of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Natalia Trayanova
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland
| | - Katherine C Wu
- Department of Medicine, Division of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Jonathan Chrispin
- Department of Medicine, Division of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland.
| |
Collapse
|
7
|
Holmström L, Zhang FZ, Ouyang D, Dey D, Slomka PJ, Chugh SS. Artificial Intelligence in Ventricular Arrhythmias and Sudden Death. Arrhythm Electrophysiol Rev 2023; 12:e17. [PMID: 37457439 PMCID: PMC10345967 DOI: 10.15420/aer.2022.42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 03/16/2023] [Indexed: 07/18/2023] Open
Abstract
Sudden cardiac arrest due to lethal ventricular arrhythmias is a major cause of mortality worldwide and results in more years of potential life lost than any individual cancer. Most of these sudden cardiac arrest events occur unexpectedly in individuals who have not been identified as high-risk due to the inadequacy of current risk stratification tools. Artificial intelligence tools are increasingly being used to solve complex problems and are poised to help with this major unmet need in the field of clinical electrophysiology. By leveraging large and detailed datasets, artificial intelligence-based prediction models have the potential to enhance the risk stratification of lethal ventricular arrhythmias. This review presents a synthesis of the published literature and a discussion of future directions in this field.
Collapse
Affiliation(s)
- Lauri Holmström
- Division of Artificial Intelligence in Medicine, Department of Medicine, Cedars-Sinai Health System, Los Angeles, CA, US
- Center for Cardiac Arrest Prevention, Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Health System, Los Angeles, CA, US
| | - Frank Zijun Zhang
- Division of Artificial Intelligence in Medicine, Department of Medicine, Cedars-Sinai Health System, Los Angeles, CA, US
| | - David Ouyang
- Division of Artificial Intelligence in Medicine, Department of Medicine, Cedars-Sinai Health System, Los Angeles, CA, US
| | - Damini Dey
- Division of Artificial Intelligence in Medicine, Department of Medicine, Cedars-Sinai Health System, Los Angeles, CA, US
| | - Piotr J Slomka
- Division of Artificial Intelligence in Medicine, Department of Medicine, Cedars-Sinai Health System, Los Angeles, CA, US
| | - Sumeet S Chugh
- Division of Artificial Intelligence in Medicine, Department of Medicine, Cedars-Sinai Health System, Los Angeles, CA, US
- Center for Cardiac Arrest Prevention, Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Health System, Los Angeles, CA, US
| |
Collapse
|
8
|
Gronthy UU, Biswas U, Tapu S, Samad MA, Nahid AA. A Bibliometric Analysis on Arrhythmia Detection and Classification from 2005 to 2022. Diagnostics (Basel) 2023; 13:diagnostics13101732. [PMID: 37238216 DOI: 10.3390/diagnostics13101732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 04/28/2023] [Accepted: 05/11/2023] [Indexed: 05/28/2023] Open
Abstract
Bibliometric analysis is a widely used technique for analyzing large quantities of academic literature and evaluating its impact in a particular academic field. In this paper bibliometric analysis has been used to analyze the academic research on arrhythmia detection and classification from 2005 to 2022. We have followed PRISMA 2020 framework to identify, filter and select the relevant papers. This study has used the Web of Science database to find related publications on arrhythmia detection and classification. "Arrhythmia detection", "arrhythmia classification" and "arrhythmia detection and classification" are three keywords for gathering the relevant articles. 238 publications in total were selected for this research. In this study, two different bibliometric techniques, "performance analysis" and "science mapping", were applied. Different bibliometric parameters such as publication analysis, trend analysis, citation analysis, and networking analysis have been used to evaluate the performance of these articles. According to this analysis, the three countries with the highest number of publications and citations are China, the USA, and India in terms of arrhythmia detection and classification. The three most significant researchers in this field are those named U. R. Acharya, S. Dogan, and P. Plawiak. Machine learning, ECG, and deep learning are the three most frequently used keywords. A further finding of the study indicates that the popular topics for arrhythmia identification are machine learning, ECG, and atrial fibrillation. This research provides insight into the origins, current status, and future direction of arrhythmia detection research.
Collapse
Affiliation(s)
- Ummay Umama Gronthy
- Electronics and Communication Engineering Discipline, Khulna University, Khulna 9208, Bangladesh
| | - Uzzal Biswas
- Electronics and Communication Engineering Discipline, Khulna University, Khulna 9208, Bangladesh
| | - Salauddin Tapu
- Electronics and Communication Engineering Discipline, Khulna University, Khulna 9208, Bangladesh
| | - Md Abdus Samad
- Department of Information and Communication Engineering, Yeungnam University, Gyeongsan-si 38541, Republic of Korea
| | - Abdullah-Al Nahid
- Electronics and Communication Engineering Discipline, Khulna University, Khulna 9208, Bangladesh
| |
Collapse
|
9
|
Wu KC. Myocardial Tissue Characterization to Predict Ventricular Arrhythmic Risk: Road Well-Traveled But So Far to Go. JACC Cardiovasc Imaging 2023; 16:639-641. [PMID: 36707355 PMCID: PMC10159956 DOI: 10.1016/j.jcmg.2022.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 12/13/2022] [Indexed: 01/26/2023]
Affiliation(s)
- Katherine C Wu
- Division of Cardiology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
| |
Collapse
|
10
|
Barker J, Li X, Khavandi S, Koeckerling D, Mavilakandy A, Pepper C, Bountziouka V, Chen L, Kotb A, Antoun I, Mansir J, Smith-Byrne K, Schlindwein FS, Dhutia H, Tyukin I, Nicolson WB, Ng GA. Machine learning in sudden cardiac death risk prediction: a systematic review. Europace 2022; 24:1777-1787. [PMID: 36201237 DOI: 10.1093/europace/euac135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/07/2022] [Indexed: 11/23/2022] Open
Abstract
AIMS Most patients who receive implantable cardioverter defibrillators (ICDs) for primary prevention do not receive therapy during the lifespan of the ICD, whilst up to 50% of sudden cardiac death (SCD) occur in individuals who are considered low risk by conventional criteria. Machine learning offers a novel approach to risk stratification for ICD assignment. METHODS AND RESULTS Systematic search was performed in MEDLINE, Embase, Emcare, CINAHL, Cochrane Library, OpenGrey, MedrXiv, arXiv, Scopus, and Web of Science. Studies modelling SCD risk prediction within days to years using machine learning were eligible for inclusion. Transparency and quality of reporting (TRIPOD) and risk of bias (PROBAST) were assessed. A total of 4356 studies were screened with 11 meeting the inclusion criteria with heterogeneous populations, methods, and outcome measures preventing meta-analysis. The study size ranged from 122 to 124 097 participants. Input data sources included demographic, clinical, electrocardiogram, electrophysiological, imaging, and genetic data ranging from 4 to 72 variables per model. The most common outcome metric reported was the area under the receiver operator characteristic (n = 7) ranging between 0.71 and 0.96. In six studies comparing machine learning models and regression, machine learning improved performance in five. No studies adhered to a reporting standard. Five of the papers were at high risk of bias. CONCLUSION Machine learning for SCD prediction has been under-applied and incorrectly implemented but is ripe for future investigation. It may have some incremental utility in predicting SCD over traditional models. The development of reporting standards for machine learning is required to improve the quality of evidence reporting in the field.
Collapse
Affiliation(s)
- Joseph Barker
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Cardiology Department, Glenfield Hospital, University Hospitals Leicester, Leicester, UK
| | - Xin Li
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- School of Engineering, University of Leicester, Leicester, UK
| | - Sarah Khavandi
- Faculty of Medicine, Imperial College School of Medicine, Imperial College London, London, UK
| | - David Koeckerling
- Division of Angiology, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Akash Mavilakandy
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Coral Pepper
- Library and Information Service, University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | - Long Chen
- School of Computing and Mathematical Sciences, University of Leicester, Leicester, UK
| | - Ahmed Kotb
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Cardiology Department, Glenfield Hospital, University Hospitals Leicester, Leicester, UK
| | - Ibrahim Antoun
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | | | - Karl Smith-Byrne
- Cancer Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Fernando S Schlindwein
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- School of Engineering, University of Leicester, Leicester, UK
| | - Harshil Dhutia
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Cardiology Department, Glenfield Hospital, University Hospitals Leicester, Leicester, UK
| | - Ivan Tyukin
- Department of Mathematics, University of Leicester, Leicester, UK
| | - William B Nicolson
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Cardiology Department, Glenfield Hospital, University Hospitals Leicester, Leicester, UK
| | - G Andre Ng
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Cardiology Department, Glenfield Hospital, University Hospitals Leicester, Leicester, UK
- Cardiovascular Theme, National Institute for Health Research, Leicester Biomedical Research Centre, Leicester, UK
| |
Collapse
|
11
|
de Lepper AGW, Buck CMA, van 't Veer M, Huberts W, van de Vosse FN, Dekker LRC. From evidence-based medicine to digital twin technology for predicting ventricular tachycardia in ischaemic cardiomyopathy. JOURNAL OF THE ROYAL SOCIETY, INTERFACE 2022; 19:20220317. [PMID: 36128708 DOI: 10.1098/rsif.2022.0317] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Survivors of myocardial infarction are at risk of life-threatening ventricular tachycardias (VTs) later in their lives. Current guidelines for implantable cardioverter defibrillators (ICDs) implantation to prevent VT-related sudden cardiac death is solely based on symptoms and left ventricular ejection fraction. Catheter ablation of scar-related VTs is performed following ICD therapy, reducing VTs, painful shocks, anxiety, depression and worsening heart failure. We postulate that better prediction of the occurrence and circuit of VT, will improve identification of patients at risk for VT and boost preventive ablation, reducing mortality and morbidity. For this purpose, multiple time-evolving aspects of the underlying pathophysiology, including the anatomical substrate, triggers and modulators, should be part of VT prediction models. We envision digital twins as a solution combining clinical expertise with three prediction approaches: evidence-based medicine (clinical practice), data-driven models (data science) and mechanistic models (biomedical engineering). This paper aims to create a mutual understanding between experts in the different fields by providing a comprehensive description of the clinical problem and the three approaches in an understandable manner, leveraging future collaborations and technological innovations for clinical decision support. Moreover, it defines open challenges and gains for digital twin solutions and discusses the potential of hybrid modelling.
Collapse
Affiliation(s)
| | - Carlijn M A Buck
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Marcel van 't Veer
- Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands.,Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Wouter Huberts
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands.,Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Frans N van de Vosse
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Lukas R C Dekker
- Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands.,Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| |
Collapse
|
12
|
Xie E, Sung E, Saad E, Trayanova N, Wu KC, Chrispin J. Advanced imaging for risk stratification for ventricular arrhythmias and sudden cardiac death. Front Cardiovasc Med 2022; 9:884767. [PMID: 36072882 PMCID: PMC9441865 DOI: 10.3389/fcvm.2022.884767] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 08/02/2022] [Indexed: 11/13/2022] Open
Abstract
Sudden cardiac death (SCD) is a leading cause of mortality, comprising approximately half of all deaths from cardiovascular disease. In the US, the majority of SCD (85%) occurs in patients with ischemic cardiomyopathy (ICM) and a subset in patients with non-ischemic cardiomyopathy (NICM), who tend to be younger and whose risk of mortality is less clearly delineated than in ischemic cardiomyopathies. The conventional means of SCD risk stratification has been the determination of the ejection fraction (EF), typically via echocardiography, which is currently a means of determining candidacy for primary prevention in the form of implantable cardiac defibrillators (ICDs). Advanced cardiac imaging methods such as cardiac magnetic resonance imaging (CMR), single-photon emission computerized tomography (SPECT) and positron emission tomography (PET), and computed tomography (CT) have emerged as promising and non-invasive means of risk stratification for sudden death through their characterization of the underlying myocardial substrate that predisposes to SCD. Late gadolinium enhancement (LGE) on CMR detects myocardial scar, which can inform ICD decision-making. Overall scar burden, region-specific scar burden, and scar heterogeneity have all been studied in risk stratification. PET and SPECT are nuclear methods that determine myocardial viability and innervation, as well as inflammation. CT can be used for assessment of myocardial fat and its association with reentrant circuits. Emerging methodologies include the development of "virtual hearts" using complex electrophysiologic modeling derived from CMR to attempt to predict arrhythmic susceptibility. Recent developments have paired novel machine learning (ML) algorithms with established imaging techniques to improve predictive performance. The use of advanced imaging to augment risk stratification for sudden death is increasingly well-established and may soon have an expanded role in clinical decision-making. ML could help shift this paradigm further by advancing variable discovery and data analysis.
Collapse
Affiliation(s)
- Eric Xie
- Division of Cardiology, Department of Medicine, Section of Cardiac Electrophysiology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Eric Sung
- Division of Cardiology, Department of Medicine, Section of Cardiac Electrophysiology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, United States
| | - Elie Saad
- Division of Cardiology, Department of Medicine, Section of Cardiac Electrophysiology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Natalia Trayanova
- Division of Cardiology, Department of Medicine, Section of Cardiac Electrophysiology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, United States
| | - Katherine C. Wu
- Division of Cardiology, Department of Medicine, Section of Cardiac Electrophysiology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jonathan Chrispin
- Division of Cardiology, Department of Medicine, Section of Cardiac Electrophysiology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| |
Collapse
|
13
|
Monlezun DJ, Sinyavskiy O, Peters N, Steigner L, Aksamit T, Girault MI, Garcia A, Gallagher C, Iliescu C. Artificial Intelligence-Augmented Propensity Score, Cost Effectiveness and Computational Ethical Analysis of Cardiac Arrest and Active Cancer with Novel Mortality Predictive Score. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58081039. [PMID: 36013506 PMCID: PMC9412828 DOI: 10.3390/medicina58081039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/27/2022] [Accepted: 07/29/2022] [Indexed: 11/08/2022]
Abstract
Background and objectives: Little is known about outcome improvements and disparities in cardiac arrest and active cancer. We performed the first known AI and propensity score (PS)-augmented clinical, cost-effectiveness, and computational ethical analysis of cardio-oncology cardiac arrests including left heart catheterization (LHC)-related mortality reduction and related disparities. Materials and methods: A nationally representative cohort analysis was performed for mortality and cost by active cancer using the largest United States all-payer inpatient dataset, the National Inpatient Sample, from 2016 to 2018, using deep learning and machine learning augmented propensity score-adjusted (ML-PS) multivariable regression which informed cost-effectiveness and ethical analyses. The Cardiac Arrest Cardio-Oncology Score (CACOS) was then created for the above population and validated. The results informed the computational ethical analysis to determine ethical and related policy recommendations. Results: Of the 101,521,656 hospitalizations, 6,656,883 (6.56%) suffered cardiac arrest of whom 61,300 (0.92%) had active cancer. Patients with versus without active cancer were significantly less likely to receive an inpatient LHC (7.42% versus 20.79%, p < 0.001). In ML-PS regression in active cancer, post-arrest LHC significantly reduced mortality (OR 0.18, 95%CI 0.14−0.24, p < 0.001) which PS matching confirmed by up to 42.87% (95%CI 35.56−50.18, p < 0.001). The CACOS model included the predictors of no inpatient LHC, PEA initial rhythm, metastatic malignancy, and high-risk malignancy (leukemia, pancreas, liver, biliary, and lung). Cost-benefit analysis indicated 292 racial minorities and $2.16 billion could be saved annually by reducing racial disparities in LHC. Ethical analysis indicated the convergent consensus across diverse belief systems that such disparities should be eliminated to optimize just and equitable outcomes. Conclusions: This AI-guided empirical and ethical analysis provides a novel demonstration of LHC mortality reductions in cardio-oncology cardiac arrest and related disparities, along with an innovative predictive model that can be integrated within the digital ecosystem of modern healthcare systems to improve equitable clinical and public health outcomes.
Collapse
Affiliation(s)
- Dominique J. Monlezun
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
- UNESCO Chair in Bioethics & Human Rights, 00163 Rome, Italy; (A.G.); (C.G.)
- School of Bioethics, Universidad Anahuac México, Mexico City 52786, Mexico;
- Center for Artificial Intelligence and Health Equities, Global System Analytics & Structures, New Orleans, LA 70112, USA; (N.P.); (L.S.)
- Correspondence: or or
| | - Oleg Sinyavskiy
- Department of Public Health, Asfendiyarov Kazakh National Medical University, Almaty 050000, Kazakhstan;
| | - Nathaniel Peters
- Center for Artificial Intelligence and Health Equities, Global System Analytics & Structures, New Orleans, LA 70112, USA; (N.P.); (L.S.)
| | - Lorraine Steigner
- Center for Artificial Intelligence and Health Equities, Global System Analytics & Structures, New Orleans, LA 70112, USA; (N.P.); (L.S.)
| | - Timothy Aksamit
- Department of Pulmonary Medicine, Mayo Clinic, Rochester, MN 55905, USA;
| | - Maria Ines Girault
- School of Bioethics, Universidad Anahuac México, Mexico City 52786, Mexico;
| | - Alberto Garcia
- UNESCO Chair in Bioethics & Human Rights, 00163 Rome, Italy; (A.G.); (C.G.)
- School of Bioethics, Universidad Anahuac México, Mexico City 52786, Mexico;
| | - Colleen Gallagher
- UNESCO Chair in Bioethics & Human Rights, 00163 Rome, Italy; (A.G.); (C.G.)
- Pontifical Academy for Life, 00193 Rome, Italy
- Section of Integrated Ethics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Cezar Iliescu
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| |
Collapse
|
14
|
Sapp JL. Myocardial Scar and Clustered Ventricular Arrhythmias: Imaging Is Part of the Picture. JACC Clin Electrophysiol 2022; 8:967-969. [PMID: 35981801 DOI: 10.1016/j.jacep.2022.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 06/29/2022] [Indexed: 10/15/2022]
Affiliation(s)
- John L Sapp
- Department of Medicine, Dalhousie University and QEII Health Sciences Centre, Halifax, Nova Scotia, Canada.
| |
Collapse
|
15
|
Monomorphic VT Non-Inducibility after Electrical Storm Ablation Reduces Mortality and Recurrences. J Clin Med 2022; 11:jcm11133887. [PMID: 35807170 PMCID: PMC9267206 DOI: 10.3390/jcm11133887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 06/28/2022] [Accepted: 07/01/2022] [Indexed: 02/01/2023] Open
Abstract
Background: Electrical storm (ES) is defined by clustering episodes of ventricular tachycardia (VT) and is associated with severe long-term outcomes. We sought to evaluate the prognostic impact of radiofrequency catheter ablation (RFCA) in ES as assessed by aggressive programmed ventricular stimulation (PVS). Methods: Single-center retrospective longitudinal study with 82 consecutive ES patients referred for RFCA with a median follow-up (IQR 25−75%) of 45.43 months (15−69.86). All-cause mortality and VT recurrences were assessed in relation to RFCA outcomes defined by 4-extrastimuli PVS: Class 1—no ventricular arrhythmia; Class 2—no sustained monomorphic VTs (mVT) inducible, but non-sustained mVTs, polymorphic VTs, or VF inducible; Class 3—clinical VT non-inducible, other sustained mVTs inducible; and Class 4—clinical VT inducible. Results: Class 1, Class 2, Class 3, and Class 4 were achieved in 56.1%, 13.4%, 23.2%, and 7.4% of cases, respectively. The combined outcome of Class 1 + Class 2 (no sustained monomorphic VT inducible) led to improved survival (log-rank p < 0.001) and reduced VT recurrence (log-rank p < 0.001). Residual monomorphic VT inducibility (HR 6.262 (95% CI: 2.165−18.108, p = 0.001), NYHA IV heart failure symptoms (HR 20.519 (95% CI: 1.623−259.345), p = 0.02)), and age (HR 1.009 (95% CI: 1.041−1.160), p = 0.001)) independently predicted death during follow-up. LVEF was not predictive of death (HR 1.003 (95% CI: 0.946−1.063) or recurrences (HR 0.988 (95% CI: 0.955−1.021)). Conclusions: Non-inducibility for sustained mVTs after aggressive PVS post-RFCA leads to improved survival in ES, independently of LVEF.
Collapse
|
16
|
Vakil RM, Marine JE, Kolandaivelu A, Dickfeld T, Weiss RG, Tomaselli GF, Chrispin J, Wu KC. The Association of Clustered Ventricular Arrhythmia and Cycle Length With Scar Burden in Cardiomyopathy. JACC Clin Electrophysiol 2022; 8:957-966. [PMID: 35981800 PMCID: PMC10111293 DOI: 10.1016/j.jacep.2022.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 05/13/2022] [Accepted: 05/18/2022] [Indexed: 10/16/2022]
Abstract
BACKGROUND Patients with ≥2 ventricular arrhythmia (VA) events within 3 months (clustered VA) have increased risk for mortality. OBJECTIVES The aim of this study was to examine the association of risk factors including scar characteristics on cardiovascular magnetic resonance imaging with clustered VA and VA cycle length in nonischemic cardiomyopathy (NICM) and ischemic cardiomyopathy (ICM). METHODS Data from 329 primary prevention implantable cardioverter-defibrillator recipients (mean age 57 years, 26% women) were analyzed from the Left Ventricular Structural Predictors of Sudden Cardiac Death study. RESULTS Twenty-one patients developed clustered VA (median time 2.7 years after implantable cardioverter-defibrillator placement). Men had the greatest risk for recurrent VA. Patients with NICM and scar had the highest incidence rate of clustered VA. In patients with NICM, each 1-g increase in core scar correlated with greater clustered VA risk (HR: 1.19; 95% CI: 1.07-1.32). Gray scar was similar among subgroups. Patients with NICM with clustered VA had the longest mean VA cycle length (297 ± 40 milliseconds). Higher core scar burden correlated with longer VA cycle length in patients with NICM (P = 0.002), and higher body mass index correlated with shorter VA cycle length in those with ICM (P = 0.02). Type of VA was similar between cardiomyopathy subgroups, and no scar pattern predominated. CONCLUSIONS Clustered VA was most common in patients with NICM and scar, with greatest risk among those with larger core scar. Core scar correlated with slower VA in patients with NICM, and higher body mass index correlated with faster VA in those with ICM. Type of VA was similar by cardiomyopathy etiology, and no dominant scar pattern was associated with clustered VA.
Collapse
|
17
|
Brown G, Conway S, Ahmad M, Adegbie D, Patel N, Myneni V, Alradhawi M, Kumar N, Obaid DR, Pimenta D, Bray JJH. Role of artificial intelligence in defibrillators: a narrative review. Open Heart 2022; 9:openhrt-2022-001976. [PMID: 35790317 PMCID: PMC9258481 DOI: 10.1136/openhrt-2022-001976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 05/17/2022] [Indexed: 02/01/2023] Open
Abstract
Automated external defibrillators (AEDs) and implantable cardioverter defibrillators (ICDs) are used to treat life-threatening arrhythmias. AEDs and ICDs use shock advice algorithms to classify ECG tracings as shockable or non-shockable rhythms in clinical practice. Machine learning algorithms have recently been assessed for shock decision classification with increasing accuracy. Outside of rhythm classification alone, they have been evaluated in diagnosis of causes of cardiac arrest, prediction of success of defibrillation and rhythm classification without the need to interrupt cardiopulmonary resuscitation. This review explores the many applications of machine learning in AEDs and ICDs. While these technologies are exciting areas of research, there remain limitations to their widespread use including high processing power, cost and the ‘black-box’ phenomenon.
Collapse
Affiliation(s)
- Grace Brown
- Cardiology Department, Royal Free Hospital, London, UK
| | - Samuel Conway
- Cardiology Department, Royal Free Hospital, London, UK
| | - Mahmood Ahmad
- Medical Sciences, University College London, London, UK
| | - Divine Adegbie
- Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, UK
| | - Nishil Patel
- Cardiology Department, North Middlesex University Hospital, London, UK
| | | | | | - Niraj Kumar
- Institute of Cardiovascular Science, University College London, London, UK.,Cardiology Department, Barts Health NHS Trust, London, UK
| | - Daniel R Obaid
- Institute of Life Sciences, Swansea University, Swansea, UK
| | - Dominic Pimenta
- Cardiology Department, Richmond Research Institute, London, UK
| | - Jonathan J H Bray
- Cardiff University College of Biomedical and Life Sciences, Cardiff, UK
| |
Collapse
|
18
|
Samuel TJ, Lai S, Schär M, Wu KC, Steinberg AM, Wei AC, Anderson M, Tomaselli GF, Gerstenblith G, Bottomley PA, Weiss RG. Myocardial ATP depletion detected noninvasively predicts sudden cardiac death risk in heart failure patients. JCI Insight 2022; 7:157557. [PMID: 35579938 PMCID: PMC9309047 DOI: 10.1172/jci.insight.157557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 05/06/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Sudden cardiac death (SCD) remains a worldwide public health problem in need of better noninvasive predictive tools. Current guidelines for primary preventive SCD therapies, such as implantable cardioverter defibrillators (ICDs), are based on left ventricular ejection fraction (LVEF), but these guidelines are imprecise: fewer than 5% of ICDs deliver lifesaving therapy per year. Impaired cardiac metabolism and ATP depletion cause arrhythmias in experimental models, but to our knowledge a link between arrhythmias and cardiac energetic abnormalities in people has not been explored, nor has the potential for metabolically predicting clinical SCD risk. METHODS We prospectively measured myocardial energy metabolism noninvasively with phosphorus magnetic resonance spectroscopy in patients with no history of significant arrhythmias prior to scheduled ICD implantation for primary prevention in the setting of reduced LVEF (≤35%). RESULTS By 2 different analyses, low myocardial ATP significantly predicted the composite of subsequent appropriate ICD firings for life-threatening arrhythmias and cardiac death over approximately 10 years. Life-threatening arrhythmia risk was approximately 3-fold higher in patients with low ATP and independent of established risk factors, including LVEF. In patients with normal ATP, rates of appropriate ICD firings were several-fold lower than reported rates of ICD complications and inappropriate firings. CONCLUSION To the best of our knowledge, these are the first data linking in vivo myocardial ATP depletion and subsequent significant arrhythmic events in people, suggesting an energetic component to clinical life-threatening ventricular arrhythmogenesis. The findings support investigation of metabolic strategies that limit ATP loss to treat or prevent life-threatening cardiac arrhythmias and herald noninvasive metabolic imaging as a complementary SCD risk stratification tool. TRIAL REGISTRATION ClinicalTrials.gov NCT00181233. FUNDING This work was supported by the DW Reynolds Foundation, the NIH (grants HL61912, HL056882, HL103812, HL132181, HL140034), and Russell H. Morgan and Clarence Doodeman endowments at Johns Hopkins.
Collapse
Affiliation(s)
- T Jake Samuel
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - Shenghan Lai
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, United States of America
| | - Michael Schär
- Division of Magnetic Resonance Research, Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - Katherine C Wu
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - Angela M Steinberg
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - An-Chi Wei
- Department of Electrical Engineering, National Taiwan University, Tapei, Taiwan
| | - Mark Anderson
- Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, United States of America
| | - Gordon F Tomaselli
- Division of Cardiology, Department of Medicine, The Albert Einstein College of Medicine, Bronx, United States of America
| | - Gary Gerstenblith
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - Paul A Bottomley
- Division of Magnetic Resonance Research, Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - Robert G Weiss
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, United States of America
| |
Collapse
|
19
|
Wu KC, Chrispin J. More Than Meets the Eye: Cardiac Magnetic Resonance Image Entropy and Ventricular Arrhythmia Risk Prediction. JACC Cardiovasc Imaging 2022; 15:793-795. [PMID: 35331659 DOI: 10.1016/j.jcmg.2022.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 01/06/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Katherine C Wu
- Division of Cardiology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
| | - Jonathan Chrispin
- Division of Cardiology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| |
Collapse
|
20
|
Chung CT, Bazoukis G, Lee S, Liu Y, Liu T, Letsas KP, Armoundas AA, Tse G. Machine learning techniques for arrhythmic risk stratification: a review of the literature. INTERNATIONAL JOURNAL OF ARRHYTHMIA 2022; 23. [PMID: 35449883 PMCID: PMC9020640 DOI: 10.1186/s42444-022-00062-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Ventricular arrhythmias (VAs) and sudden cardiac death (SCD) are significant adverse events that affect the morbidity and mortality of both the general population and patients with predisposing cardiovascular risk factors. Currently, conventional disease-specific scores are used for risk stratification purposes. However, these risk scores have several limitations, including variations among validation cohorts, the inclusion of a limited number of predictors while omitting important variables, as well as hidden relationships between predictors. Machine learning (ML) techniques are based on algorithms that describe intervariable relationships. Recent studies have implemented ML techniques to construct models for the prediction of fatal VAs. However, the application of ML study findings is limited by the absence of established frameworks for its implementation, in addition to clinicians’ unfamiliarity with ML techniques. This review, therefore, aims to provide an accessible and easy-to-understand summary of the existing evidence about the use of ML techniques in the prediction of VAs. Our findings suggest that ML algorithms improve arrhythmic prediction performance in different clinical settings. However, it should be emphasized that prospective studies comparing ML algorithms to conventional risk models are needed while a regulatory framework is required prior to their implementation in clinical practice.
Collapse
|
21
|
Daimee UA, Sung E, Engels M, Halushka MK, Berger RD, Trayanova NA, Wu KC, Chrispin J. Association of Left Ventricular Tissue Heterogeneity and Intramyocardial Fat on Computed Tomography with Ventricular Arrhythmias in Ischemic Cardiomyopathy. Heart Rhythm O2 2022; 3:241-247. [PMID: 35734302 PMCID: PMC9207722 DOI: 10.1016/j.hroo.2022.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background Gray zone, a measure of tissue heterogeneity on late gadolinium enhanced–cardiac magnetic resonance (LGE-CMR) imaging, has been shown to predict ventricular arrhythmias (VAs) in ischemic cardiomyopathy (ICM) patients. However, no studies have described whether left ventricular (LV) tissue heterogeneity and intramyocardial fat mass on contrast-enhanced computed tomography (CE-CT), which provides greater spatial resolution, is useful for assessing the risk of VAs in ICM patients with LV systolic dysfunction and no previous VAs. Objective The purpose of this proof-of-concept study was to determine the feasibility of measuring global LV tissue heterogeneity and intramyocardial fat mass by CE-CT for predicting the risk of VAs in ICM patients with LV systolic dysfunction and no previous history of VAs. Methods Patients with left ventricular ejection fraction ≤35% and no previous VAs were enrolled in a prospective, observational registry and underwent LGE-CMR. From this cohort, patients with ICM who additionally received CE-CT were included in the present analysis. Gray zone on LGE-CMR was defined as myocardium with signal intensity (SI) > peak SI of healthy myocardium but <50% maximal SI. Tissue heterogeneity on CE-CT was defined as the standard deviation of the Hounsfield unit image gradients (HU/mm) within the myocardium. Intramyocardial fat on CE-CT was identified as regions of image pixels between –180 and –5 HU. The primary outcome was VAs, defined as appropriate implantable cardioverter-defibrillator shock or sudden arrhythmic death. Results The study consisted of 47 ICM patients, 13 (27.7%) of whom experienced VA events during mean follow-up of 5.6 ± 3.4 years. Increasing tissue heterogeneity (per HU/mm) was significantly associated with VAs after multivariable adjustment, including for gray zone (odds ratio [OR] 1.22; P = .019). Consistently, patients with tissue heterogeneity values greater than or equal to the median (≥22.2 HU/mm) had >13-fold significantly increased risk of VA events, relative to patients with values lower than the median, after multivariable adjustment that included gray zone (OR 13.13; P = .028). The addition of tissue heterogeneity to gray zone improved prediction of VAs (area under receiver operating characteristic curve increased from 0.815 to 0.876). No association was found between intramyocardial fat mass on CE-CT and VAs (OR 1.00; P = .989). Conclusion In ICM patients, CE-CT–derived LV tissue heterogeneity was independently associated with VAs and may represent a novel marker useful for risk stratification.
Collapse
|
22
|
Popescu DM, Shade JK, Lai C, Aronis KN, Ouyang D, Moorthy MV, Cook NR, Lee DC, Kadish A, Albert CM, Wu KC, Maggioni M, Trayanova NA. Arrhythmic sudden death survival prediction using deep learning analysis of scarring in the heart. NATURE CARDIOVASCULAR RESEARCH 2022; 1:334-343. [PMID: 35464150 DOI: 10.1038/s44161-022-00041-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Sudden cardiac death from arrhythmia is a major cause of mortality worldwide. Here, we develop a novel deep learning (DL) approach that blends neural networks and survival analysis to predict patient-specific survival curves from contrast-enhanced cardiac magnetic resonance images and clinical covariates for patients with ischemic heart disease. The DL-predicted survival curves offer accurate predictions at times up to 10 years and allow for estimation of uncertainty in predictions. The performance of this learning architecture was evaluated on multi-center internal validation data and tested on an independent test set, achieving concordance index of 0.83 and 0.74, and 10-year integrated Brier score of 0.12 and 0.14. We demonstrate that our DL approach with only raw cardiac images as input outperforms standard survival models constructed using clinical covariates. This technology has the potential to transform clinical decision-making by offering accurate and generalizable predictions of patient-specific survival probabilities of arrhythmic death over time.
Collapse
Affiliation(s)
- Dan M Popescu
- Alliance for Cardiovascular Diagnostic and Treatment Innovation (ADVANCE), Johns Hopkins University, Baltimore, 21224, USA
| | - Julie K Shade
- Alliance for Cardiovascular Diagnostic and Treatment Innovation (ADVANCE), Johns Hopkins University, Baltimore, 21224, USA
| | - Changxin Lai
- Johns Hopkins University School of Medicine, Department of Biomedical Engineering, Baltimore, 21224, USA
| | - Konstantinos N Aronis
- University of Pittsburgh Medical Center, Heart and Vascular Institute, Pittsburgh, 15237, USA
| | - David Ouyang
- Cedar-Sinai Medical Center, Department of Cardiology, Los Angeles, 90048, USA
| | - M Vinayaga Moorthy
- Brigham and Women's Hospital, Harvard Medical School, Boston, 02115, USA
| | - Nancy R Cook
- Brigham and Women's Hospital, Harvard Medical School, Boston, 02115, USA
| | - Daniel C Lee
- Northwestern University, Feinberg School of Medicine, Chicago, 60611, USA
| | - Alan Kadish
- Touro College and University System, Valhalla, 10595, USA
| | - Christine M Albert
- Cedar-Sinai Medical Center, Department of Cardiology, Los Angeles, 90048, USA
| | - Katherine C Wu
- Alliance for Cardiovascular Diagnostic and Treatment Innovation (ADVANCE), Johns Hopkins University, Baltimore, 21224, USA.,Johns Hopkins University School of Medicine, Department of Medicine, Division of Cardiology, Baltimore, 21224, USA
| | - Mauro Maggioni
- Alliance for Cardiovascular Diagnostic and Treatment Innovation (ADVANCE), Johns Hopkins University, Baltimore, 21224, USA.,Johns Hopkins University, Department of Applied Mathematics and Statistics, Baltimore, 21224, USA
| | - Natalia A Trayanova
- Alliance for Cardiovascular Diagnostic and Treatment Innovation (ADVANCE), Johns Hopkins University, Baltimore, 21224, USA.,Johns Hopkins University School of Medicine, Department of Biomedical Engineering, Baltimore, 21224, USA
| |
Collapse
|
23
|
Nedios S, Iliodromitis K, Kowalewski C, Bollmann A, Hindricks G, Dagres N, Bogossian H. Big Data in electrophysiology. Herzschrittmacherther Elektrophysiol 2022; 33:26-33. [PMID: 35137276 DOI: 10.1007/s00399-022-00837-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 01/07/2022] [Indexed: 06/14/2023]
Abstract
The quantity of data produced and captured in medicine today is unprecedented. Technological improvements and automation have expanded the traditional statistical methods and enabled the analysis of Big Data. This has permitted the discovery of new associations with a granularity that was previously hidden to human eyes. In the first part of this review, the authors would like to provide an overview of basic Machine Learning (ML) principles and techniques in order to better understand their application in recent publications about cardiac arrhythmias. In the second part, ML-enabled advances in disease detection and diagnosis, outcome prediction, and novel disease characterization in topics like electrocardiography, atrial fibrillation, ventricular arrhythmias, and cardiac devices are presented. Finally, the limitations and challenges of applying ML in clinical practice, such as validation, replication, generalizability, and regulatory issues, are discussed. More carefully designed studies and collaborations are needed for ML to become feasible, trustworthy, accurate, and reproducible and to reach its full potential for patient-oriented precision medicine.
Collapse
Affiliation(s)
- Sotirios Nedios
- Department of Electrophysiology, Heart Center Leipzig at the University of Leipzig, Leipzig, Germany.
- Rhythmologie, Herzzentrum Leipzig, Universität Leipzig, Strümpellstr. 39, 04289, Leipzig, Germany.
| | - Konstantinos Iliodromitis
- Department of Cardiology and Rhythmology, Ev. Krankenhaus Hagen, Hagen, Germany
- Department of Cardiology, University Witten/Herdecke, Witten, Germany
| | - Christopher Kowalewski
- Department of Electrophysiology, Heart Center Leipzig at the University of Leipzig, Leipzig, Germany
| | - Andreas Bollmann
- Department of Electrophysiology, Heart Center Leipzig at the University of Leipzig, Leipzig, Germany
| | - Gerhard Hindricks
- Department of Electrophysiology, Heart Center Leipzig at the University of Leipzig, Leipzig, Germany
| | - Nikolaos Dagres
- Department of Electrophysiology, Heart Center Leipzig at the University of Leipzig, Leipzig, Germany
| | - Harilaos Bogossian
- Department of Cardiology and Rhythmology, Ev. Krankenhaus Hagen, Hagen, Germany
- Department of Cardiology, University Witten/Herdecke, Witten, Germany
| |
Collapse
|
24
|
Krebs J, Mansi T, Delingette H, Lou B, Lima JAC, Tao S, Ciuffo LA, Norgard S, Butcher B, Lee WH, Chamera E, Dickfeld TM, Stillabower M, Marine JE, Weiss RG, Tomaselli GF, Halperin H, Wu KC, Ashikaga H. CinE caRdiac magneTic resonAnce to predIct veNTricular arrhYthmia (CERTAINTY). Sci Rep 2021; 11:22683. [PMID: 34811411 PMCID: PMC8608832 DOI: 10.1038/s41598-021-02111-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 11/10/2021] [Indexed: 12/24/2022] Open
Abstract
Better models to identify individuals at low risk of ventricular arrhythmia (VA) are needed for implantable cardioverter-defibrillator (ICD) candidates to mitigate the risk of ICD-related complications. We designed the CERTAINTY study (CinE caRdiac magneTic resonAnce to predIct veNTricular arrhYthmia) with deep learning for VA risk prediction from cine cardiac magnetic resonance (CMR). Using a training cohort of primary prevention ICD recipients (n = 350, 97 women, median age 59 years, 178 ischemic cardiomyopathy) who underwent CMR immediately prior to ICD implantation, we developed two neural networks: Cine Fingerprint Extractor and Risk Predictor. The former extracts cardiac structure and function features from cine CMR in a form of cine fingerprint in a fully unsupervised fashion, and the latter takes in the cine fingerprint and outputs disease outcomes as a cine risk score. Patients with VA (n = 96) had a significantly higher cine risk score than those without VA. Multivariate analysis showed that the cine risk score was significantly associated with VA after adjusting for clinical characteristics, cardiac structure and function including CMR-derived scar extent. These findings indicate that non-contrast, cine CMR inherently contains features to improve VA risk prediction in primary prevention ICD candidates. We solicit participation from multiple centers for external validation.
Collapse
Affiliation(s)
- Julian Krebs
- Digital Technology and Innovation Division, Siemens Healthineers, Princeton, NJ, USA
- Université Côte d'Azur, Inria, Epione Team, Sophia Antipolis, France
| | - Tommaso Mansi
- Digital Technology and Innovation Division, Siemens Healthineers, Princeton, NJ, USA
| | - Hervé Delingette
- Université Côte d'Azur, Inria, Epione Team, Sophia Antipolis, France
| | - Bin Lou
- Digital Technology and Innovation Division, Siemens Healthineers, Princeton, NJ, USA
| | - Joao A C Lima
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Carnegie 568, Baltimore, MD, 21287, USA
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Susumu Tao
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Carnegie 568, Baltimore, MD, 21287, USA
| | - Luisa A Ciuffo
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Carnegie 568, Baltimore, MD, 21287, USA
| | - Sanaz Norgard
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Carnegie 568, Baltimore, MD, 21287, USA
| | - Barbara Butcher
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Carnegie 568, Baltimore, MD, 21287, USA
| | - Wei H Lee
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Carnegie 568, Baltimore, MD, 21287, USA
| | - Ela Chamera
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Carnegie 568, Baltimore, MD, 21287, USA
| | | | | | - Joseph E Marine
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Carnegie 568, Baltimore, MD, 21287, USA
| | - Robert G Weiss
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Carnegie 568, Baltimore, MD, 21287, USA
| | | | - Henry Halperin
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Carnegie 568, Baltimore, MD, 21287, USA
| | - Katherine C Wu
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Carnegie 568, Baltimore, MD, 21287, USA
| | - Hiroshi Ashikaga
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Carnegie 568, Baltimore, MD, 21287, USA.
| |
Collapse
|
25
|
Aronis KN, Okada DR, Xie E, Daimee UA, Prakosa A, Gilotra NA, Wu KC, Trayanova N, Chrispin J. Spatial dispersion analysis of LGE-CMR for prediction of ventricular arrhythmias in patients with cardiac sarcoidosis. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:2067-2074. [PMID: 34766627 DOI: 10.1111/pace.14406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 10/15/2021] [Accepted: 11/07/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Patients with cardiac sarcoidosis (CS) are at increased risk of life-threatening ventricular arrhythmias (VA). Current approaches to risk stratification have limited predictive value. OBJECTIVES To assess the utility of spatial dispersion analysis of late gadolinium enhancement cardiac magnetic resonance (LGE-CMR), as a quantitative measure of myocardial tissue heterogeneity, in risk stratifying patients with CS for VA and death. METHODS Sixty two patients with CS underwent LGE-CMR. LGE images were segmented and dispersion maps of the left and right ventricles were generated as follows. Based on signal intensity (SI), each pixel was categorized as abnormal (SI ≥3SD above the mean), intermediate (SI 1-3 SD above the mean) or normal (SI <1SD above the mean); and each pixel was then assigned a value of 0 to 8 based on the number of adjacent pixels of a different category. Average dispersion score was calculated for each patient. The primary endpoint was VA during follow up. The composite of VA or death was assessed as a secondary endpoint. RESULTS During 4.7 ± 3.5 years of follow up, six patients had VA, and five without documented VA died. Average dispersion score was significantly higher in patients with VA versus those without (0.87 ± 0.08 vs. 0.71 ± 0.16; p = .002) and in patients with events versus those without (0.83 ± 0.08 vs. 0.70 ± 0.16; p = .003). Patients at higher tertiles of dispersion score had a higher incidence of VA (p = .03) and the composite of VA or death (p = .01). CONCLUSIONS Increased substrate heterogeneity, quantified by spatial dispersion analysis of LGE-CMR, may be helpful in risk-stratifying patients with CS for adverse events, including life-threatening arrhythmias.
Collapse
Affiliation(s)
- Konstantinos N Aronis
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA.,Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, Maryland, USA
| | - David R Okada
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Eric Xie
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Usama A Daimee
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Adityo Prakosa
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, USA.,Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, Maryland, USA
| | - Nisha A Gilotra
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Katherine C Wu
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Natalia Trayanova
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, USA.,Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jonathan Chrispin
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA.,Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, Maryland, USA
| |
Collapse
|
26
|
Amoni M, Dries E, Ingelaere S, Vermoortele D, Roderick HL, Claus P, Willems R, Sipido KR. Ventricular Arrhythmias in Ischemic Cardiomyopathy-New Avenues for Mechanism-Guided Treatment. Cells 2021; 10:2629. [PMID: 34685609 PMCID: PMC8534043 DOI: 10.3390/cells10102629] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 09/20/2021] [Accepted: 09/23/2021] [Indexed: 12/13/2022] Open
Abstract
Ischemic heart disease is the most common cause of lethal ventricular arrhythmias and sudden cardiac death (SCD). In patients who are at high risk after myocardial infarction, implantable cardioverter defibrillators are the most effective treatment to reduce incidence of SCD and ablation therapy can be effective for ventricular arrhythmias with identifiable culprit lesions. Yet, these approaches are not always successful and come with a considerable cost, while pharmacological management is often poor and ineffective, and occasionally proarrhythmic. Advances in mechanistic insights of arrhythmias and technological innovation have led to improved interventional approaches that are being evaluated clinically, yet pharmacological advancement has remained behind. We review the mechanistic basis for current management and provide a perspective for gaining new insights that centre on the complex tissue architecture of the arrhythmogenic infarct and border zone with surviving cardiac myocytes as the source of triggers and central players in re-entry circuits. Identification of the arrhythmia critical sites and characterisation of the molecular signature unique to these sites can open avenues for targeted therapy and reduce off-target effects that have hampered systemic pharmacotherapy. Such advances are in line with precision medicine and a patient-tailored therapy.
Collapse
Affiliation(s)
- Matthew Amoni
- Experimental Cardiology, Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium; (M.A.); (E.D.); (S.I.); (H.L.R.); (R.W.)
- Division of Cardiology, University Hospitals Leuven, 3000 Leuven, Belgium
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town 7935, South Africa
| | - Eef Dries
- Experimental Cardiology, Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium; (M.A.); (E.D.); (S.I.); (H.L.R.); (R.W.)
| | - Sebastian Ingelaere
- Experimental Cardiology, Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium; (M.A.); (E.D.); (S.I.); (H.L.R.); (R.W.)
- Division of Cardiology, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Dylan Vermoortele
- Imaging and Cardiovascular Dynamics, Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium; (D.V.); (P.C.)
| | - H. Llewelyn Roderick
- Experimental Cardiology, Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium; (M.A.); (E.D.); (S.I.); (H.L.R.); (R.W.)
| | - Piet Claus
- Imaging and Cardiovascular Dynamics, Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium; (D.V.); (P.C.)
| | - Rik Willems
- Experimental Cardiology, Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium; (M.A.); (E.D.); (S.I.); (H.L.R.); (R.W.)
- Division of Cardiology, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Karin R. Sipido
- Experimental Cardiology, Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium; (M.A.); (E.D.); (S.I.); (H.L.R.); (R.W.)
| |
Collapse
|
27
|
Sung E, Etoz S, Zhang Y, Trayanova NA. Whole-heart ventricular arrhythmia modeling moving forward: Mechanistic insights and translational applications. BIOPHYSICS REVIEWS 2021; 2:031304. [PMID: 36281224 PMCID: PMC9588428 DOI: 10.1063/5.0058050] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/19/2023]
Abstract
Ventricular arrhythmias are the primary cause of sudden cardiac death and one of the leading causes of mortality worldwide. Whole-heart computational modeling offers a unique approach for studying ventricular arrhythmias, offering vast potential for developing both a mechanistic understanding of ventricular arrhythmias and clinical applications for treatment. In this review, the fundamentals of whole-heart ventricular modeling and current methods of personalizing models using clinical data are presented. From this foundation, the authors summarize recent advances in whole-heart ventricular arrhythmia modeling. Efforts in gaining mechanistic insights into ventricular arrhythmias are discussed, in addition to other applications of models such as the assessment of novel therapeutics. The review emphasizes the unique benefits of computational modeling that allow for insights that are not obtainable by contemporary experimental or clinical means. Additionally, the clinical impact of modeling is explored, demonstrating how patient care is influenced by the information gained from ventricular arrhythmia models. The authors conclude with future perspectives about the direction of whole-heart ventricular arrhythmia modeling, outlining how advances in neural network methodologies hold the potential to reduce computational expense and permit for efficient whole-heart modeling.
Collapse
Affiliation(s)
- Eric Sung
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland 21218, USA
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, Maryland 21218, USA
| | - Sevde Etoz
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, Maryland 21218, USA
| | - Yingnan Zhang
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland 21218, USA
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, Maryland 21218, USA
| | - Natalia A. Trayanova
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland 21218, USA
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, Maryland 21218, USA
- Author to whom correspondence should be addressed: . Tel.: 410-516-4375
| |
Collapse
|
28
|
The Role of Artificial Intelligence and Machine Learning in Clinical Cardiac Electrophysiology. Can J Cardiol 2021; 38:246-258. [PMID: 34333029 DOI: 10.1016/j.cjca.2021.07.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 07/11/2021] [Accepted: 07/25/2021] [Indexed: 11/21/2022] Open
Abstract
In recent years, artificial intelligence (AI) has found numerous applications in cardiology due in part to large digitized datasets and the evolution of high performance computing. In the discipline of cardiac electrophysiology (EP), a number of clinical, imaging, and electrical waveform data are considered in the diagnosis, prognostication and management of arrhythmias, which lend themselves well to automation through AI. But equally relevant, AI offers a unique opportunity to discover novel EP concepts and improve clinical care through its inherent, hierarchical tenets of self-learning. This review will focus on the application of AI in clinical EP and summarize state-of-the art, large, clinical studies in the following key domains: (1) ECG-based arrhythmia and disease classification, (2) atrial fibrillation source detection, (3) substrate and risk assessment for atrial fibrillation and ventricular tachyarrhythmias, and (4) predicting outcomes after cardiac resynchronization therapy. Many are small, single-center, proof-of-concept investigations, but they still demonstrate groundbreaking performance of deep learning, a subdomain of AI, which surpasses traditional statistical analysis. Larger studies, for instance classifying arrhythmias from ECG recordings, have further provided external validation of their high accuracy. Ultimately, the performance of AI is dependent on the quality of the input data and the rigor of algorithm development. The field is still nascent and several barriers will need to be overcome, including prospective validation in large, well-labelled datasets and more seamless information technology-based data collection/integration, before AI can be adopted into broader clinical EP practice. This review will conclude with a discussion of these challenges and future work.
Collapse
|
29
|
Singh A, Chen W, Patel HN, Alvi N, Kawaji K, Besser SA, Tung R, Zou J, Lang RM, Mor-Avi V, Patel AR. Impact of Wideband Late Gadolinium Enhancement Cardiac Magnetic Resonance Imaging on Device-Related Artifacts in Different Implantable Cardioverter-Defibrillator Types. J Magn Reson Imaging 2021; 54:1257-1265. [PMID: 33742522 DOI: 10.1002/jmri.27608] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 03/05/2021] [Accepted: 03/10/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Late gadolinium enhancement (LGE) imaging in patients with implantable cardioverter-defibrillators (ICD) is limited by device-related artifacts (DRA). The use of wideband (WB) LGE protocols improves LGE images, but their efficacy with different ICD types is not well known. PURPOSE To assess the effects of WB LGE imaging on DRA in different non-MR conditional ICD subtypes. STUDY TYPE Retrospective. POPULATION A total of 113 patients undergoing cardiac magnetic resonance imaging with three ICD subtypes: transvenous (TV-ICD, N = 48), cardiac-resynchronization therapy device (CRT-D, N = 48), and subcutaneous (S-ICD, N = 17). FIELD STRENGTH/SEQUENCE 5 T scanner, standard LGE, and WB LGE imaging with a phase-sensitive inversion recovery segmented gradient echo sequence. ASSESSMENT DRA burden was defined as the number of artifact-positive short-axis LGE slices as percentage of the total number of short-axis slices covering the left ventricle from based to apex, and was determined for WB and standard LGE studies for each patient. Additionally, artifact area on each slice was quantified. STATISTICAL TESTS Shapiro-Wilks, Kruskal-Wallis analysis of variance, Dunn tests with Bonferroni correction, and Mann-Whitney U-test. RESULTS In patients with TV-ICD, DRA burden was significantly reduced and nearly eliminated with WB LGE compared to standard LGE imaging (median [interquartile range]: 0 [0-7]% vs. 18 [0-50]%, P < 0.05), but WB imaging had less of an impact on DRA in the CRT-D (8 [0-23]% vs. 16 [0-45]%, p = 0.12) and S-ICD (60 [15-71]% vs. 67 [50-92]%, P = 0.09) patients. Residual DRA was significantly greater (P < 0.05) for S-ICD compared to other device types with WB LGE imaging, despite the generators of all three ICD types having similar proximity to the heart. The area of S-ICD associated DRA was smaller with WB LGE (P < 0.001) than with standard LGE imaging and the artifacts had different characteristics (dark signal void instead of a bright hyperenhancement artifact). DATA CONCLUSION Although WB LGE imaging reduced the burden of DRA caused by S-ICD, the residual artifact was greater than that observed with TV-ICD and CRT-D devices. Further developments are needed to better resolve S-ICD artifacts. LEVEL OF EVIDENCE 1 TECHNICAL EFFICACY: STAGE: 5.
Collapse
Affiliation(s)
- Amita Singh
- Department of Medicine, Section of Cardiology, University of Chicago Medicine, Chicago, Illinois, USA
| | - Wensu Chen
- Department of Medicine, Section of Cardiology, University of Chicago Medicine, Chicago, Illinois, USA.,Cardiology Department, First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Hena N Patel
- Department of Medicine, Section of Cardiology, University of Chicago Medicine, Chicago, Illinois, USA
| | - Nazia Alvi
- Department of Medicine, Section of Cardiology, University of Chicago Medicine, Chicago, Illinois, USA
| | - Keigo Kawaji
- Department of Medicine, Section of Cardiology, University of Chicago Medicine, Chicago, Illinois, USA.,Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, Illinois, USA
| | - Stephanie A Besser
- Department of Medicine, Section of Cardiology, University of Chicago Medicine, Chicago, Illinois, USA
| | - Roderick Tung
- Department of Medicine, Section of Cardiology, University of Chicago Medicine, Chicago, Illinois, USA
| | - Jiangang Zou
- Cardiology Department, First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Roberto M Lang
- Department of Medicine, Section of Cardiology, University of Chicago Medicine, Chicago, Illinois, USA
| | - Victor Mor-Avi
- Department of Medicine, Section of Cardiology, University of Chicago Medicine, Chicago, Illinois, USA
| | - Amit R Patel
- Department of Medicine, Section of Cardiology, University of Chicago Medicine, Chicago, Illinois, USA
| |
Collapse
|
30
|
Abstract
Machine learning (ML), a branch of artificial intelligence, where machines learn from big data, is at the crest of a technological wave of change sweeping society. Cardiovascular medicine is at the forefront of many ML applications, and there is a significant effort to bring them into mainstream clinical practice. In the field of cardiac electrophysiology, ML applications have also seen a rapid growth and popularity, particularly the use of ML in the automatic interpretation of ECGs, which has been extensively covered in the literature. Much lesser known are the other aspects of ML application in cardiac electrophysiology and arrhythmias, such as those in basic science research on arrhythmia mechanisms, both experimental and computational; in the development of better techniques for mapping of cardiac electrical function; and in translational research related to arrhythmia management. In the current review, we examine comprehensively such ML applications as they match the scope of this journal. The current review is organized in 3 parts. The first provides an overview of general ML principles and methodologies that will afford readers of the necessary information on the subject, serving as the foundation for inviting further ML applications in arrhythmia research. The basic information we provide can serve as a guide on how one might design and conduct an ML study. The second part is a review of arrhythmia and electrophysiology studies in which ML has been utilized, highlighting the broad potential of ML approaches. For each subject, we outline comprehensively the general topics, while reviewing some of the research advances utilizing ML under the subject. Finally, we discuss the main challenges and the perspectives for ML-driven cardiac electrophysiology and arrhythmia research.
Collapse
Affiliation(s)
- Natalia A. Trayanova
- Department of Biomedical Engineering, Johns Hopkins University, 3400 North Charles Street, Baltimore, MD, USA 21218
- Alliance for Cardiovascular Diagnosis and Treatment Innovation, Whiting School of Engineering and School of Medicine, Johns Hopkins University, 3400 North Charles Street, Baltimore, MD, USA 21218
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, 733 North Broadway, Baltimore, MD, USA 21205
| | - Dan M. Popescu
- Alliance for Cardiovascular Diagnosis and Treatment Innovation, Whiting School of Engineering and School of Medicine, Johns Hopkins University, 3400 North Charles Street, Baltimore, MD, USA 21218
- Department of Applied Mathematics and Statistics, Johns Hopkins University, 3400 North Charles Street, Baltimore, MD, USA 21218
| | - Julie K. Shade
- Department of Biomedical Engineering, Johns Hopkins University, 3400 North Charles Street, Baltimore, MD, USA 21218
- Alliance for Cardiovascular Diagnosis and Treatment Innovation, Whiting School of Engineering and School of Medicine, Johns Hopkins University, 3400 North Charles Street, Baltimore, MD, USA 21218
| |
Collapse
|
31
|
Affiliation(s)
- Natalia A Trayanova
- Department of Biomedical Engineering and Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, MD
| |
Collapse
|
32
|
Feeny AK, Chung MK, Madabhushi A, Attia ZI, Cikes M, Firouznia M, Friedman PA, Kalscheur MM, Kapa S, Narayan SM, Noseworthy PA, Passman RS, Perez MV, Peters NS, Piccini JP, Tarakji KG, Thomas SA, Trayanova NA, Turakhia MP, Wang PJ. Artificial Intelligence and Machine Learning in Arrhythmias and Cardiac Electrophysiology. Circ Arrhythm Electrophysiol 2020; 13:e007952. [PMID: 32628863 PMCID: PMC7808396 DOI: 10.1161/circep.119.007952] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Artificial intelligence (AI) and machine learning (ML) in medicine are currently areas of intense exploration, showing potential to automate human tasks and even perform tasks beyond human capabilities. Literacy and understanding of AI/ML methods are becoming increasingly important to researchers and clinicians. The first objective of this review is to provide the novice reader with literacy of AI/ML methods and provide a foundation for how one might conduct an ML study. We provide a technical overview of some of the most commonly used terms, techniques, and challenges in AI/ML studies, with reference to recent studies in cardiac electrophysiology to illustrate key points. The second objective of this review is to use examples from recent literature to discuss how AI and ML are changing clinical practice and research in cardiac electrophysiology, with emphasis on disease detection and diagnosis, prediction of patient outcomes, and novel characterization of disease. The final objective is to highlight important considerations and challenges for appropriate validation, adoption, and deployment of AI technologies into clinical practice.
Collapse
Affiliation(s)
- Albert K Feeny
- Cleveland Clinic Lerner College of Medicine (A.K.F., M.K.C.), Case Western Reserve University, OH
| | - Mina K Chung
- Cleveland Clinic Lerner College of Medicine (A.K.F., M.K.C.), Case Western Reserve University, OH
- Department of Cardiovascular Medicine, Cleveland Clinic, OH (M.K.C., K.G.T., S.A.T.)
| | - Anant Madabhushi
- Department of Biomedical Engineering (A.M., M.F.), Case Western Reserve University, OH
- Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH (A.M.)
| | - Zachi I Attia
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, MN (Z.I.A., P.A.F., S.K., P.A.N., )
| | - Maja Cikes
- Department of Cardiovascular Diseases, University of Zagreb School of Medicine & University Hospital Center Zagreb, Croatia (M.C.)
| | - Marjan Firouznia
- Department of Biomedical Engineering (A.M., M.F.), Case Western Reserve University, OH
| | - Paul A Friedman
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, MN (Z.I.A., P.A.F., S.K., P.A.N., )
| | - Matthew M Kalscheur
- Division of Cardiovascular Medicine, Department of Medicine, School of Medicine & Public Health, University of Wisconsin (M.M.K.)
- William S. Middleton Veterans Hospital, Madison, WI (M.M.K.)
| | - Suraj Kapa
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, MN (Z.I.A., P.A.F., S.K., P.A.N., )
| | - Sanjiv M Narayan
- Division of Cardiovascular Medicine, Stanford University, CA (S.M.N., M.V.P., M.P.T., P.J.W.)
- Veterans Affairs Palo Alto Health Care System, CA (S.M.N., M.V.P., M.P.T., P.J.W.)
| | - Peter A Noseworthy
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, MN (Z.I.A., P.A.F., S.K., P.A.N., )
| | - Rod S Passman
- Division of Cardiology, Northwestern University, Feinberg School of Medicine, Chicago, IL (R.S.P.)
| | - Marco V Perez
- Division of Cardiovascular Medicine, Stanford University, CA (S.M.N., M.V.P., M.P.T., P.J.W.)
- Veterans Affairs Palo Alto Health Care System, CA (S.M.N., M.V.P., M.P.T., P.J.W.)
| | - Nicholas S Peters
- National Heart Lung Institute & Centre for Cardiac Engineering, Imperial College London, United Kingdom (N.S.P.)
| | - Jonathan P Piccini
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (J.P.P.)
| | - Khaldoun G Tarakji
- Department of Cardiovascular Medicine, Cleveland Clinic, OH (M.K.C., K.G.T., S.A.T.)
| | - Suma A Thomas
- Department of Cardiovascular Medicine, Cleveland Clinic, OH (M.K.C., K.G.T., S.A.T.)
| | - Natalia A Trayanova
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD (N.A.T.)
| | - Mintu P Turakhia
- Division of Cardiovascular Medicine, Stanford University, CA (S.M.N., M.V.P., M.P.T., P.J.W.)
- Veterans Affairs Palo Alto Health Care System, CA (S.M.N., M.V.P., M.P.T., P.J.W.)
- Center for Digital Health, Stanford University School of Medicine, CA (M.P.T.)
| | - Paul J Wang
- Division of Cardiovascular Medicine, Stanford University, CA (S.M.N., M.V.P., M.P.T., P.J.W.)
- Veterans Affairs Palo Alto Health Care System, CA (S.M.N., M.V.P., M.P.T., P.J.W.)
| |
Collapse
|