Development and validation of AI-derived segmentation of four-chamber cine cardiac magnetic resonance

Background Cardiac magnetic resonance (CMR) in the four-chamber plane offers comprehensive insight into the volumetrics of the heart. We aimed to develop an artificial intelligence (AI) model of time-resolved segmentation using the four-chamber cine.

Methods A fully automated deep learning algorithm was trained using retrospective multicentre and multivendor data of 814 subjects. Validation, reproducibility, and mortality prediction were evaluated on an independent cohort of 101 subjects.

Results The mean age of the validation cohort was 54 years, and 66 (65%) were males. Left and right heart parameters demonstrated strong correlations between automated and manual analysis, with a ρ of 0.91−0.98 and 0.89−0.98, respectively, with minimal bias. All AI four-chamber volumetrics in repeatability analysis demonstrated high correlation (ρ = 0.99−1.00) and no bias. Automated four-chamber analysis underestimated both left ventricular (LV) and right ventricular (RV) volumes compared to ground-truth short-axis cine analysis. Two correction factors for LV and RV four-chamber analysis were proposed based on systematic bias. After applying the correction factors, a strong correlation and minimal bias for LV volumetrics were observed. During a mean follow-up period of 6.75 years, 16 patients died. On stepwise multivariable analysis, left atrial ejection fraction demonstrated an independent association with death in both manual (hazard ratio (HR) = 0.96, p = 0.003) and AI analyses (HR = 0.96, p < 0.001).

Conclusion Fully automated four-chamber CMR is feasible, reproducible, and has the same real-world prognostic value as manual analysis. LV volumes by four-chamber segmentation were comparable to short-axis volumetric assessment.

Trials registration ClinicalTrials.gov: NCT05114785.

Relevance statement Integrating fully automated AI in CMR promises to revolutionise clinical cardiac assessment, offering efficient, accurate, and prognostically valuable insights for improved patient care and outcomes.

Key points • Four-chamber cine sequences remain one of the most informative acquisitions in CMR examination.

• This deep learning-based, time-resolved, fully automated four-chamber volumetric, functional, and deformation analysis solution.

• LV and RV were underestimated by four-chamber analysis compared to ground truth short-axis segmentation.

• Correction bias for both LV and RV volumes by four-chamber segmentation, minimises the systematic bias.