Artificial intelligence-enhanced electrocardiography to predict regurgitant valvular heart diseases: an international study

Abstract Background and Aims Valvular heart disease (VHD) is a significant source of morbidity and mortality, though early intervention can improve outcomes. This study aims to develop artificial intelligence-enhanced electrocardiography (AI-ECG) models to diagnose and predict future moderate or severe regurgitant VHDs (rVHDs), including mitral regurgitation (MR), tricuspid regurgitation (TR), and aortic regurgitation (AR). Methods The AI-ECG models were developed in a data set of 988 618 ECG and transthoracic echocardiogram pairs from 400 882 patients from Zhongshan Hospital, Shanghai, China. The AI-ECG models used a residual convolutional neural network with a discrete-time survival loss function. External evaluation was performed in outpatients from a secondary care data set from Beth Israel Deaconess Medical Center, Boston, USA, consisting of 34 214 patients with linked echocardiography. Results In the internal test set, the AI-ECG models accurately predicted future significant MR [C-index 0.774, 95% confidence interval (CI) 0.753–0.792], AR (0.691, 95% CI 0.657–0.720), and TR (0.793, 95% CI 0.777–0.808). In age- and sex-adjusted Cox models, the highest risk quartile had a hazard ratio (HR) of 7.6 (95% CI 5.8–9.9, P < .0001) for risk of future significant MR, compared with the lowest risk quartile. For future AR and TR, the equivalent HRs were 3.8 (95% CI 2.7–5.5) and 9.9 (95% CI 7.5–13.0), respectively. These findings were confirmed in the transnational external test set. Imaging association analyses demonstrated AI-ECG predictions were associated with subclinical chamber remodelling. Conclusions This study developed AI-ECG models to diagnose and predict rVHDs and validated the models in a transnational and ethnically distinct cohort. The AI-ECG models could be utilized to guide surveillance echocardiography in patients at risk of future rVHDs, to facilitate early detection and intervention.