Deep Learning-Based Automated Quantification of TIMI Myocardial Perfusion Frame Count (DL-TMPFC) from Coronary Angiography: A Novel Framework for Rapid Assessment of Microvascular Dysfunction
Authors: Si Li, Yuanqing He, Chenkai Hu, Xiaogang Guo, Huay-Cheem Tan, Chieh Yang Koo, Xuan Zhang, Lei He, +2 more
Organizations: School of Artificial Intelligence and Digital Economy Industry, Guangzhou Institute of Science and Technology, Guangzhou, China · Department of Cardiology, Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China. · Department of Cardiology, First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China. · Department of Cardiology, National University Heart Centre, Singapore.
Aims: Coronary microvascular dysfunction (CMVD) affects approximately 40%-60% of patients with ischemia and non-obstructive coronary arteries, yet diagnosis remains challenging due to reliance on invasive functional testing or subjective Thrombolysis In Myocardial Infarction (TIMI) flow grade. The TIMI Myocardial Perfusion Frame Count (TMPFC) offers an objective, angiography-based quantitative measure of CMVD, but its clinical translation is hindered by cumbersome manual calculation and insufficient validation. This study aims to develop and validate a deep learning-powered TMPFC calculation (DL-TMPFC), enabling integration into clinical workflows. Methods and results: DL-TMPFC framework comprised two components. A stenosis detection network first excluded obstructive coronary artery disease (CAD). A territory-aware segmentation network then identified perfusion territories and TMPFC calculation module automatically determined the first and last frames from angiographic sequences. The framework was validated in a cohort of 655 patients (445 of obstructive CAD, 100 of confirmed CMVD, 110 of control group) from three independent institutions. DL-TMPFC showed excellent agreement with expert manual measurements (bias: -0.93 frames; 95% LoA: -5.33 to +3.47; r =0.98). DL-TMPFC markedly enhanced clinical feasibility by fully automating TMPFC and removing observer dependence. Clinically, DL-TMPFC accurately identified CMVD across a full spectrum of coronary pathologies and captured the continuous severity of CMVD beyond binary classification, enabling quantitative risk stratification. Conclusion: DL-TMPFC enabled automatic, standardized, and accurate quantification of CMVD directly from routine angiography. By providing an automatic and objective measure, this tool provided immediate diagnostic information for timely recognition and management of CMVD in clinical practice.
Coronary artery disease, a leading cause of cardiovascular mortality worldwide, can be assessed non-invasively by coronary computed tomography angiography (CCTA). Although deep learning has advanced automated CCTA analysis, clinical translation remains constrained by the scarcity of expert-annotated data and by the spatial sparsity of coronary pathology, which occupies only a small fraction of each scan. Widely used label-free pretraining strategies, such as masked image modeling and contrastive learning, optimize for global anatomical reconstruction and tend to under-represent these tiny localized pathological features. Here we present CORA, an annotation-efficient model for comprehensive coronary artery disease assessment. Rather than reconstructing background anatomy, CORA learns from volumetric CCTA through a synthesis-driven self-supervised strategy: an anatomy-guided engine inserts diverse synthetic calcified and non-calcified lesions into unlabeled scans, reframing pretraining as an abnormality-detection task that biases representation learning toward clinically relevant disease features. We pretrained CORA on 10,138 unlabeled CCTA volumes and evaluated it across datasets from nine independent hospitals. Across plaque characterization, stenosis detection, and coronary artery segmentation, CORA consistently outperformed strong self-supervised pretraining baselines, with the largest gains on external multi-center data, indicating robust generalization under distributional shift. Coupling the imaging encoder with structured clinical variables further enabled near-term major adverse cardiac event (MACE) risk stratification. Our results show that pathology-centric, synthesis-driven pretraining is an effective and scalable strategy for annotation-efficient coronary artery disease assessment from CCTA.
Accurate pixel-level classification of coronary angiograms is critical for cardiovascular disease assessment, yet the field lacks standardized evaluation protocols. In this work we demonstrate a new benchmark for the assessment of deep learning models which densely classify pixels of coronary angiograms to one of SYNTAX classes (or background). The evaluation covers 24 distinct architectures starting with classic convnets to recent state-space-based vision algorithms. We release CARDIAG - a multi-center, multi-label dataset which we carefully split to reliably compute metrics, accounting for diameter error, overlap, centerline quality and calibration. The data contains SYNTAX labels, binary, uncertainty and segmentation masks as well as intermediate frames together with the selected non-sensitive DICOM metadata. From the multitude of algorithms, we nominate ConvNeXt V2 encoder with DeepLab V3 Plus decoder as the best performing, achieving macro F1=0.456, which we then ensemble with Mamba U-Net and Feature Pyramid Network, for an increased F1=0.479. We demonstrate all the architectures to be well calibrated and determine the generalization of the top 5 methods, together with the data efficiency of these architectures. We highlight the importance of both high-resolution and low-resolution features in encoding. We also demonstrate the model correctness in the context of patient demographic, vessel sides and projection angle configurations. Overall the released benchmark allows for future studies to robustly and rigorously assess the proposals, not only for SYNTAX segmentation, but lesion detection and many more.
Dominik Bernard Lau, Hubert Malinowski, Jerzy Szyjut +5
Clinical decision-making for coronary intervention relies mainly on angiography and fractional flow reserve (FFR). However, angiography is two-dimensional and lacks depth information for 3D lesion characterization, while FFR provides only a single functional index, offering limited hemodynamic insight. Among existing methods, numerical analysis is computationally expensive, whereas learning-based approaches require extensive supervision and often lack physical consistency. To address these limitations, we propose physics-informed hemodynamic modeling, an integrated deep learning framework for 3D coronary blood flow analysis from dual-view angiography. First, an attention-enhanced CNN reconstructs coronary geometry from angiography. The resulting point clouds are then mapped to a reference domain and Fourier-encoded for joint representation. A decoupled network separately predicts velocity and pressure fields, with embedded physical priors enabling efficient transfer across physiological conditions. Across 32 clinical patients evaluated under four flow conditions, the trans-stenotic pressure-drop mean absolute percentage error was 2.02%, while the velocity and pressure relative-L2 errors were 0.054 and 0.023, respectively. Validation against hospital-measured FFR further achieved 93.8% diagnostic accuracy (30/32; exact 95% CI, 79.2%-99.2%). The framework also supports illustrative revascularization comparisons and sparse-data assimilation, with the full angiography-to-hemodynamics pipeline completed within 20 minutes per patient.