A Novel Approach to Identifying Hibernating Myocardium Using Radiomics-Based Machine Learning.

Background To assess the feasibility of a machine learning (ML) approach using radiomics features of perfusion defects on rest myocardial perfusion imaging (MPI) to detect the presence of hibernating myocardium. Methodology Data of patients who underwent 99mTc-sestamibi MPI and 18F-FDG PET/CT for myocardial viability assessment were retrieved. Rest MPI data were processed on ECToolbox, and polar maps were saved using the NFile PMap tool. The reference standard for defining hibernating myocardium was the presence of mismatched perfusion-metabolism defect with impaired myocardial contractility at rest. Perfusion defects on the polar maps were delineated with regions of interest (ROIs) after spatial resampling and intensity discretization. Replicable random sampling allocated 80% (257) of the perfusion defects of the patients from January 2017 to September 2022 to the training set and the remaining 20% (64) to the validation set. An independent dataset of perfusion defects from 29 consecutive patients from October 2022 to January 2023 was used as the testing set for model evaluation. One hundred ten first and second-order texture features were extracted for each ROI. After feature normalization and imputation, 14 best-ranked features were selected using a multistep feature selection process including the Logistic Regression and Fast Correlation-Based Filter. Thirteen supervised ML algorithms were trained with stratified five-fold cross-validation on the training set and validated on the validation set. The ML algorithms with a Log Loss of <0.688 and <0.672 in the cross-validation and validation steps were evaluated on the testing set. Performance matrices of the algorithms assessed included area under the curve (AUC), classification accuracy (CA), F1 score, precision, recall, and specificity. To provide transparency and interpretability, SHapley Additive exPlanations (SHAP) values were assessed and depicted as beeswarm plots. Results Two hundred thirty-nine patients (214 males; mean age 56 ± 11 years) were enrolled in the study. There were 371 perfusion defects (321 in the training and validation sets; 50 in the testing set). Based on the reference standard, 168 perfusion defects had hibernating myocardium (139 in the training and validation sets; 29 in the testing set). On cross-validation, six ML algorithms with Log Loss <0.688 had AUC >0.800. On validation, 10 ML algorithms had a Log Loss value <0.672, among which six had AUC >0.800. On model evaluation of the selected models on the unseen testing set, nine ML models had AUC >0.800 with Gradient Boosting Random Forest (xgboost) [GB RF (xgboost)] achieving the highest AUC of 0.860 and could detect the presence of hibernating myocardium in 21/29 (72.4%) perfusion defects with a precision of 87.5% (21/24), specificity 85.7% (18/21), CA 78.0% (39/50) and F1 Score 0.792. Four models depicted a clear pattern of model interpretability based on the beeswarm SHAP plots. These were GB RF (xgboost), GB (scikit-learn), GB (xgboost), and Random Forest. Conclusion Our study demonstrates the potential of ML in detecting hibernating myocardium using radiomics features extracted from perfusion defects on rest MPI images. This proof-of-concept underscores the notion that radiomics features capture nuanced information beyond what is perceptible to the human eye, offering promising avenues for improved myocardial viability assessment.