EchoDino: A pediatric foundation model for transferable echocardiographic analysis across the lifespan

Echocardiography is a widely used modality for cardiac assessment due to its non-invasive and cost-effective nature, but the sparse and heterogeneous spatiotemporal views of the heart pose distinct challenges. Existing masked autoencoder (MAE) approaches typically process images or short clips independently, failing to capture the inherent multi-view structure required for coherent cardiac representation. We introduce Latent Attention Masked Autoencoder (LAMAE), a foundation model architecture tailored to the multi-view nature of medical imaging. LAMAE augments the standard MAE with a latent attention module that enables information exchange across frames and views directly in latent space. This allows the model to aggregate variable-length sequences and distinct views, reconstructing a holistic representation of cardiac function from partial observations. We pretrain LAMAE on MIMIC-IV-ECHO, a large-scale, uncurated dataset reflecting real-world clinical variability. To the best of our knowledge, we present the first results for predicting ICD-10 codes from MIMIC-IV-ECHO videos. Furthermore, we empirically demonstrate that representations learned from adult data transfer effectively to pediatric cohorts despite substantial anatomical differences. These results provide evidence that incorporating structural priors, such as multi-view attention, yields significantly more robust and transferable representations.

Self-supervised learning (SSL) is increasingly used in medical imaging to reduce annotation requirements, but representation quality is often judged using a single downstream evaluation setting. For dense clinical tasks, this can confound representation quality with the capacity of the downstream model used to recover task-relevant information. We present a systematic evaluation of self-supervised representations for left-ventricular segmentation and ejection fraction (EF) estimation from apical four-chamber echocardiography on EchoNet-Dynamic. Rather than relying on a single downstream probe, we compare a hierarchy of extraction strategies with increasing expressivity: heuristic extraction without mask-supervised training, frozen linear probes, frozen lightweight decoder probes, and partial fine-tuning. We apply this framework to two complementary representation families: generic frozen self-DIstillation with NO labels (DINOv3) features and a task-adapted dense self-supervised representation, Bootstrap Your Own Segmentation (BYOS). In both families, heuristic extraction substantially understated what was recoverable from the frozen representation. For DINOv3, performance improved from Dice 0.684 and EF mean absolute error (MAE) 13.01 under heuristic extraction to Dice 0.906 and EF MAE 9.65 with a frozen lightweight decoder, approaching a supervised U-Net baseline (Dice 0.915, EF MAE 9.72). For BYOS, performance improved from Dice 0.687 and EF MAE 17.83 under heuristic extraction to Dice 0.902 and EF MAE 8.74 with a frozen lightweight decoder. These results show that conclusions about self-supervised representation quality in dense echocardiographic analysis depend strongly on the downstream extraction strategy used for evaluation. We therefore argue that multi-strategy evaluation is an important methodological consideration for SSL in dense medical image analysis.

We introduce EchoXFlow, a clinical echocardiography dataset for learning from ultrasound in its native acquisition geometry rather than from scan-converted Cartesian videos. Existing public datasets offer limited opportunities to study cross-modal relationships between cardiac anatomy, myocardial motion, and blood flow, as Doppler is typically absent or fused as RGB overlays, and acquisitions are released after lossy vendor display processing. EchoXFlow comprises 37125 recordings from 666 routine-care examinations, preserving the timing, geometry, and modality relationships needed for physically grounded echo learning. Each recording is retained as separable modality-specific streams: temporally resolved 1D, 2D, and 3D data alongside multiple Doppler modalities, paired with a synchronized ECG. Clinical annotations span guideline-based measurements to dense 2D myocardial contours and 3D left-ventricular endocardial meshes. With its associated open-source tooling, EchoXFlow enables cross-modal, acquisition-aware learning tasks that cannot be formulated from conventional scan-converted videos alone, and serves as a testbed for 4D vision and physically grounded multi-modal learning more broadly.