MARCUS: An agentic, multimodal vision-language model for cardiac diagnosis and management

Cardiovascular disease remains the leading cause of global mortality, with progress hindered by human interpretation of complex cardiac tests. Current AI vision-language models are limited to single-modality inputs and are non-interactive. We present MARCUS (Multimodal Autonomous Reasoning and Chat for Ultrasound and Signals), an agentic vision-language system for end-to-end interpretation of electrocardiograms (ECGs), echocardiograms, and cardiac magnetic resonance imaging (CMR) independently and as multimodal input. MARCUS employs a hierarchical agentic architecture comprising modality-specific vision-language expert models, each integrating domain-trained visual encoders with multi-stage language model optimization, coordinated by a multimodal orchestrator. Trained on 13.5 million images (0.25M ECGs, 1.3M echocardiogram images, 12M CMR images) and our novel expert-curated dataset spanning 1.6 million questions, MARCUS achieves state-of-the-art performance surpassing frontier models (GPT-5 Thinking, Gemini 2.5 Pro Deep Think). Across internal (Stanford) and external (UCSF) test cohorts, MARCUS achieves accuracies of 87-91% for ECG, 67-86% for echocardiography, and 85-88% for CMR, outperforming frontier models by 34-45% (P<0.001). On multimodal cases, MARCUS achieved 70% accuracy, nearly triple that of frontier models (22-28%), with 1.7-3.0x higher free-text quality scores. Our agentic architecture also confers resistance to mirage reasoning, whereby vision-language models derive reasoning from unintended textual signals or hallucinated visual content. MARCUS demonstrates that domain-specific visual encoders with an agentic orchestrator enable multimodal cardiac interpretation. We release our models, code, and benchmark open-source.

Whole Heart Perfusion with High-Multiband Simultaneous Multislice Imaging via Linear Phase Modulated Extended Field of View (SMILE)

Purpose: To develop a simultaneous multislice (SMS) first-pass perfusion technique that can achieve whole heart coverage with high multi-band factors, while avoiding the issue of slice leakage. Methods: The proposed Simultaneous Multislice Imaging via Linear phase modulated Extended field of view (SMILE) treats the SMS acquisition and reconstruction within an extended field of view framework, allowing arbitrarily under-sampling of phase encoding lines of the extended k-space matrix and enabling the direct application of 2D parallel imaging reconstruction techniques. We presented a theoretical framework that offers insights into the performance of SMILE. We performed retrospective comparison on 28 subjects and prospective perfusion experiments on 49 patients undergoing routine clinical CMR studies with SMILE at multiband (MB) factors of 3-5, with a total acceleration factor ($R$) of 8 and 10 respectively, and compared SMILE to conventional SMS techniques using standard FOV 2D CAIPI acquisition and standard 2D slice separation techniques including split-slice GRAPPA and ROCK-SPIRiT. Results: Retrospective studies demonstrated 5.2 to 8.0 dB improvement in signal to error ratio (SER) of SMILE over CAIPI perfusion. Prospective studies showed good image quality with grades of 4.5 $\pm$ 0.5 for MB=3, $R$=8 and 3.6 $\pm$ 0.8 for MB=5, $R$=10. (5-point Likert Scale) Conclusion: The theoretical derivation and experimental results validate the SMILE's improved performance at high acceleration and MB factors as compared to the existing 2D CAIPI SMS acquisition and reconstruction techniques for first-pass myocardial perfusion imaging.