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Original Investigation
January 22, 2020

Prediction of Pulmonary to Systemic Flow Ratio in Patients With Congenital Heart Disease Using Deep Learning–Based Analysis of Chest Radiographs

Author Affiliations
  • 1Department of Thoracic and Cardiovascular Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
  • 2Department of Pediatrics, Mie University Graduate School of Medicine, Tsu, Mie, Japan
  • 3Mie Prefectural General Medical Center, Yokkaichi, Mie, Japan
JAMA Cardiol. Published online January 22, 2020. doi:10.1001/jamacardio.2019.5620
Key Points

Question  Does deep learning–based analysis of chest radiographs predict the pulmonary to systemic flow ratio in patients with congenital heart disease?

Findings  This retrospective observational study using 1031 cardiac catheterizations and chest radiographs showed that the pulmonary to systemic flow ratio predicted by a deep learning model was significantly correlated with the values calculated using the Fick method (intraclass correlation coefficient, 0.68). The diagnostic concordance rate of the model was significantly higher than that of experts (64 of 100 cases vs 49 of 100 cases).

Meaning  These results may allow clinicians to quantify otherwise qualitative and subjective findings of pulmonary vascularity in chest radiographs.

Abstract

Importance  Chest radiography is a useful noninvasive modality to evaluate pulmonary blood flow status in patients with congenital heart disease. However, the predictive value of chest radiography is limited by the subjective and qualitive nature of the interpretation. Recently, deep learning has been used to analyze various images, but it has not been applied to analyzing chest radiographs in such patients.

Objective  To develop and validate a quantitative method to predict the pulmonary to systemic flow ratio from chest radiographs using deep learning.

Design, Setting, and Participants  This retrospective observational study included 1031 cardiac catheterizations performed for 657 patients from January 1, 2005, to April 30, 2019, at a tertiary center. Catheterizations without the Fick-derived pulmonary to systemic flow ratio or chest radiography performed within 1 month before catheterization were excluded. Seventy-eight patients (100 catheterizations) were randomly assigned for evaluation. A deep learning model that predicts the pulmonary to systemic flow ratio from chest radiographs was developed using the method of transfer learning.

Main Outcomes and Measures  Whether the model can predict the pulmonary to systemic flow ratio from chest radiographs was evaluated using the intraclass correlation coefficient and Bland-Altman analysis. The diagnostic concordance rate was compared with 3 certified pediatric cardiologists. The diagnostic performance for a high pulmonary to systemic flow ratio of 2.0 or more was evaluated using cross tabulation and a receiver operating characteristic curve.

Results  The study included 1031 catheterizations in 657 patients (522 males [51%]; median age, 3.4 years [interquartile range, 1.2-8.6 years]), in whom the mean (SD) Fick-derived pulmonary to systemic flow ratio was 1.43 (0.95). Diagnosis included congenital heart disease in 1008 catheterizations (98%). The intraclass correlation coefficient for the Fick-derived and deep learning–derived pulmonary to systemic flow ratio was 0.68, the log-transformed bias was 0.02, and the log-transformed precision was 0.12. The diagnostic concordance rate of the deep learning model was significantly higher than that of the experts (correctly classified 64 of 100 vs 49 of 100 chest radiographs; P = .02 [McNemar test]). For detecting a high pulmonary to systemic flow ratio, the sensitivity of the deep learning model was 0.47, the specificity was 0.95, and the area under the receiver operating curve was 0.88.

Conclusions and Relevance  The present investigation demonstrated that deep learning–based analysis of chest radiographs predicted the pulmonary to systemic flow ratio in patients with congenital heart disease. These findings suggest that the deep learning–based approach may confer an objective and quantitative evaluation of chest radiographs in the congenital heart disease clinic.

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