A Multimodal and Explainable Machine Learning Approach to Diagnosing Multi-Class Ejection Fraction from Electrocardiograms
Authors: Catherine Ning, Yu Ma, Cindy Beini Wang, Sean McMahon, Joseph Radojevic, Steven Zweibel, Dimitris Bertsimas
Organizations: Operations Research Center, Massachusetts Institute of Technology, Cambridge, MA, USA · Wisconsin School of Business, University of Wisconsin–Madison, Madison, WI, USA · Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
Abstract
Left ventricular ejection fraction (LVEF) assessment depends on echocardiography, limiting access in primary care and resource-constrained settings. We developed a multimodal machine-learning framework that combines engineered 12-lead ECG timeseries features with structured EHR variables to classify LVEF into four clinically used strata: normal (>50%), mildly reduced (40-50%), moderately reduced (30-40%), and severely reduced (<30%). To support model explainability, we identified the most influential ECG and EHR features via SHAP attributions. Using retrospective data from Hartford HealthCare, we trained XGBoost models on 36,784 ECG-echocardiogram pairs from 30,952 outpatients and evaluated temporal generalizability on 19,966 ECGs from a subsequent period. The multimodal model achieved one-vs-rest AUROCs of 0.95 (severe), 0.92 (moderate), 0.82 (mild), and 0.91 (normal), outperforming ECG-only and EHR-only baselines, and maintained performance under temporal validation. This work supports ECG-based, multimodal LVEF stratification as a practical screening and triage aid to prioritize confirmatory imaging where resources are limited.
We present, to the best of our knowledge, the first publicly available resource for predicting left ventricular ejection fraction (EF) from parasternal long-axis (PLAX) echocardiography. Because no PLAX-EF datasets previously existed, our work focuses on an innovative data generation strategy to overcome this scarcity. By leveraging a time-based correlation between clinical notes and echocardiographic videos, combined with fine-tuning view classifiers and proxy labeling, we created a labeled dataset of over 25,000 PLAX videos. This enables us to train the first reproducible PLAX EF model, achieving a mean absolute error (MAE) of 6.86%. Given that apical four-chamber (A4C) methods, the clinical standard, report MAE values of 6%-7%, our results demonstrate that EF estimation from PLAX views is both feasible and clinically relevant. This surpasses the performance of existing methods and provides a clinically relevant solution for situations where apical views may not be feasible. Going further, we demonstrate that combining PLAX and A4C predictions via simple unweighted late fusion improves both single-view baselines to a 6.37% MAE, underscoring the value of multi-view integration. To promote continued research, we release the dataset labels, trained models, and runnable demos on GitHub, Hugging Face, and Google Colab: https://github.com/Jeffrey4899/PLAX_EF_Labels_202509
Transthoracic echocardiography is the reference standard for confirming structural heart disease (SHD), but first-line screening is limited by cost, workflow burden, and specialist availability. We evaluated whether open pretrained electrocardiogram (ECG) foundation models can support echo-confirmed multi-label SHD detection using the public EchoNext Mini-Model benchmark. Six echocardiography-derived abnormalities were targeted: reduced left ventricular ejection fraction, increased left ventricular wall thickness, aortic stenosis, mitral regurgitation, tricuspid regurgitation, and right ventricular systolic dysfunction. Under a common pipeline, we compared engineered ECG features with gradient boosting, end-to-end waveform learning from scratch, and transfer from open ECG foundation models. We then applied in-domain self-supervised adaptation of an ECG foundation model (ECG-FM) on EchoNext waveforms followed by selective supervised fine-tuning, and evaluated trade-offs between discrimination and adaptation cost. Adapted ECG-FM models achieved the best overall performance: peak macro-AUROC 0.8509 and macro-AUPRC 0.4297, while a parameter-efficient operating point preserved AUROC (0.8501) and attained the highest fixed-threshold macro-F1 0.3691. Late fusion with covariates did not improve threshold-independent discrimination, and evaluated LoRA, alternative backbones, and mixture-of-foundations strategies did not surpass the best adapted single-backbone models. These results indicate that for ECG-based case finding and echocardiography triage, combining target-domain self-supervised adaptation with selective supervised updating of a pretrained ECG backbone is the most effective transfer strategy.
Left ventricular ejection fraction (LVEF) is a primary marker of cardiac function. However, routine estimation from endocardial measurements requires manual delineation at end-diastole (ED) and end-systole (ES), a process that is time-consuming and subject to inter-observer variability. Reliable automation is especially valuable for point-of-care ultrasound (POCUS), where computational resources are limited and acquisition quality varies. We propose Echo-E3Net, an anatomy-guided spatio-temporal network that explicitly embeds cardiac anatomy into LVEF prediction. A dual-phase Endocardial Border Detector (E2CBD) uses phase-specific cross-attention to localize ED/ES endocardial landmarks and produce phase-aware landmark embeddings, while an Endocardial Feature Aggregator (E2FA) fuses these embeddings with global statistical descriptors of deep feature maps to refine EF regression. Training is guided by a lightweight geometric loss that uses ED and ES endocardial landmarks to regularize EF prediction. On EchoNet-Dynamic and a PSAX subset of EchoNet-Pediatric, Echo-E3Net attains competitive performance using only 1.55M parameters and 8.05 GFLOPs, an order-of-magnitude compute reduction versus recent baselines, supporting real-time deployment. Our code is publicly available at https://github.com/moeinheidari7829/Echo-E3Net.