An artificial intelligence‐enabled electrocardiogram algorithm for the prediction of left atrial low‐voltage areas in persistent atrial fibrillation

Abstract Objectives We aimed to construct an artificial intelligence‐enabled electrocardiogram (ECG) algorithm that can accurately predict the presence of left atrial low‐voltage areas (LVAs) in patients with persistent atrial fibrillation. Methods The study included 587 patients with persistent atrial fibrillation who underwent catheter ablation procedures between March 2012 and December 2023 and 942 scanned images of 12‐lead ECGs obtained before the ablation procedures were performed. Artificial intelligence‐based algorithms were used to construct models for predicting the presence of LVAs. The DR‐FLASH and APPLE clinical scores for LVA prediction were calculated. We used a receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis to evaluate model performance. Results The data obtained from the participants were split into training ( n = 469), validation ( n = 58), and test sets ( n = 60). LVAs were detected in 53.7% of all participants. Using ECG alone, the deep learning algorithm achieved an area under the ROC curve (AUROC) of 0.752, outperforming both the DR‐FLASH score (AUROC = 0.610) and the APPLE score (AUROC = 0.510). The random forest classification model, which integrated a probabilistic deep learning model and clinical features, showed a maximum AUROC of 0.759. Moreover, the ECG‐based deep learning algorithm for predicting extensive LVAs achieved an AUROC of 0.775, with a sensitivity of 0.816 and a specificity of 0.896. The random forest classification model for predicting extensive LVAs achieved an AUROC of 0.897, with a sensitivity of 0.862, and a specificity of 0.935. Conclusion The deep learning model based exclusively on ECG data and the machine learning model that combined a probabilistic deep learning model and clinical features both predicted the presence of LVAs with a higher degree of accuracy than the DR‐FLASH and the APPLE risk scores.