Physiology and Anatomy Aware Inverse Inference of Myocardial Infarction for Cardiac Digital Twin

Accurate localization of myocardial infarction is essential for risk stratification. While LGE-MRI remains the gold standard, it is resource-intensive. Integrating cine MRI with ECG enables a more detailed representation of infarct properties. Existing inverse MI inference methods overlook realistic scar morphology and cardiac repolarization, reducing sensitivity to subtle ECG variations and interpretability of infarct-induced electrophysiological changes. In this paper, we propose a novel framework for noninvasive MI localization using cardiac digital twins. To bridge the domain gap between simulation and reality, we introduce an anatomy-aware stochastic infarct synthesis strategy to synthesize realistic, irregular scars with border zones, mimicking ischemic transmural progression. We then construct a virtual cohort to simulate QRS-T waveforms, capturing both depolarization and repolarization dynamics. Furthermore, we design a Physiology and Anatomy Aware Network (PAA-Net) that jointly encodes 3D myocardial geometry and multi-lead ECGs to infer infarct areas with varying localizations, sizes, spatial extents, and transmuralities. Experimental results demonstrate that our framework significantly outperforms existing methods in inverse inference, achieving Dice scores of 0.7391 and 0.5503 for scar and border zone segmentation, respectively, while further enhancing the interpretability of the ECG-infarct relationship. Our code will be released upon acceptance.

Uncertainty-aware classification and triage of structural heart disease using electrocardiography and echocardiography metrics

Machine learning methods provide a methodological innovation that can help screen for cardiovascular disease through noninvasive and readily available measurement modalities. Recent investments in using electrocardiogram (ECG) data to screen for structural heart disease (SHD) are one example, where ECGs provide a low-cost, available modality for screening. This has led to the EchoNext dataset, a paired ECG-echocardiogram data repository for testing new methods of SHD detection. However, relatively few studies have investigated how more probabilistic classification through Bayesian inference may improve uncertainty quantification in this setting. Moreover, few studies have considered how triage systems can be developed to alleviate healthcare bottlenecks, such as the review of data from underserved, rural clinics by expert sonographers for SHD assessment. In this study, we leverage existing ECG-echocardiogram data to compare frequentist and Bayesian neural network classifiers. We show that the Bayesian approach is comparable or better than frequentist methods in SHD classification, and that they have a more robust uncertainty quantification attached to them. We provide an example of how this uncertainty-aware classification scheme can be used for screening SHD, providing a proof-of-concept for how machine learning can help with triage in getting individuals expert sonographer input when SHD is highly likely or measurements are highly uncertain.

CogAdapt: Transferring Clinical ECG Foundation Models to Wearable Cognitive Load Assessment via Lead Adaptation

Real-time cognitive load assessment is essential for adaptive human-computer interaction but remains challenging due to limited labeled data and poor cross-subject generalization. Recent ECG foundation models pre-trained on millions of clinical recordings offer rich representations, but cannot be directly applied to wearable devices due to sensor configuration mismatch and task differences. In this paper, we propose CogAdapt, a framework that adapts clinical ECG foundation models to wearable cognitive load assessment. CogAdapt introduces LeadBridge, a learnable adapter that transforms 3-lead wearable signals into anatomically consistent 12-lead representations, and ProFine, a progressive fine-tuning strategy that gradually unfreezes encoder layers while preventing catastrophic forgetting. Evaluations on two public datasets (CLARE and CL-Drive) under leave-one-subject-out cross-validation show that CogAdapt substantially outperforms baselines trained from scratch, achieving macro-F1 scores of 0.626 and 0.768. These results demonstrate the promise of foundation model adaptation for subject-independent cognitive load assessment from wearable sensors.

ExECG: An Explainable AI Framework for ECG models

Deep learning has enabled ECG diagnostic models with strong performance in tasks such as arrhythmia classification and abnormality detection. However, accuracy alone is insufficient for clinical deployment because it does not explain why a specific output was produced, limiting justification, error analysis, and trust. Although ECG XAI has been extensively investigated and steadily improved, practical pipelines and reporting conventions vary across studies, hindering reuse and reproducibility. To address these issues, we present Explainable AI framework for ECG models (ExECG), a Python framework that provides a three-stage pipeline: Wrapper standardizes access across heterogeneous ECG formats and intermediate representations, Explainer unifies diverse XAI methods under a shared execution protocol, and Visualizer supports consistent cross-method comparison within a unified interface. We demonstrate end-to-end usage with concise examples and two case studies, highlighting interoperable and reproducible ECG explainability.

CLIC: Contextual Language-Informed Cardiac Pathology Classification

The electrocardiogram (ECG) is the gold standard for non-invasive diagnosis of cardiac pathologies and is a fundamental pillar of cardiovascular medicine. Recent progress in deep learning has led to the development of robust automated classifiers that achieve high performance by processing raw physiological signals. However, in clinical practice, diagnosis is rarely based solely on the signal. Cardiologists commonly support their interpretation with the patient's characteristics and the specific data-acquisition context. Despite this, most current algorithms remain restricted to signal-only analysis, failing to integrate technical metadata and demographic variables. This paper proposes Contextual Language-Informed Cardiac pathology classification (CLIC), a multimodal framework that significantly enhances diagnostic precision by encoding these variables through natural language. We demonstrate that translating patient-level contextual data into descriptive text provides an informative anchor that helps the model disambiguate complex physiological patterns. We further investigate the use of Large Language Models to synthesize richer clinical descriptions and observe that, while these generated texts remain competitive, controlled template-based contextual clinical text leads to consistent improvements in downstream classification performance.

BiFedKD: Bidirectional Federated Knowledge Distillation Framework for Non-IID and Long-Tailed ECG Monitoring

Electrocardiogram (ECG) monitoring in Internet of Medical Things (IoMT) networks is constrained by strict data-sharing regulations and privacy concerns. Federated learning (FL) enables collaborative learning by keeping raw ECG data on devices, but frequent transmissions of high-dimensional model updates incur heavy per-round traffic over bandwidth-limited links. To alleviate this bottleneck, federated distillation (FD) replaces parameter exchange with logit-based knowledge transfer. However, the performance of FD often degrades under the non-independent and identically distributed (non-IID) and long-tailed label distributions in ECG deployments. To address these challenges, we propose a bidirectional federated knowledge distillation (BiFedKD) framework that employs an aggregation-by-distillation pipeline with temperature scaling to produce a stable global distillation signal for cross-client alignment. Experiments on the MIT-BIH Arrhythmia dataset show that BiFedKD improves accuracy and Macro-F1 over the baseline by $3.52\%$ and $9.93\%$, respectively. Moreover, to reach the same Macro-F1, BiFedKD reduces communication overhead by $40\%$ and computation cost by $71.7\%$ compared with the baseline.

Compact Latent Manifold Translation: A Parameter-Efficient Foundation Model for Cross-Modal and Cross-Frequency Physiological Signal Synthesis

The analysis of physiological time series, such as electrocardiograms (ECG) and photoplethysmograms (PPG), is persistently hindered by modality and frequency gaps stemming from heterogeneous recording devices. Existing foundation models typically rely on continuous latent spaces, which frequently suffer from severe modality entanglement, lack high-fidelity cross-frequency generative capacity, and impose high computational costs that prohibit edge-device deployment. In this paper, we propose Compact Latent Manifold Translation (CLMT), a highly parameter-efficient (0.09B) unified framework that bridges these gaps through a novel two-stage discrete translation paradigm. First, we introduce a Universal Tokenizer utilizing Hierarchical Residual Vector Quantization (RVQ) to decouple heterogeneous signals into isolated, well-structured discrete latent manifolds, effectively preventing inter-modality interference. Second, a Context-Prompted Latent Translator maps these discrete tokens across modalities by integrating static physiological priors, reframing complex signal synthesis as a pure latent sequence translation task. Extensive evaluations demonstrate that our 0.09B model significantly outperforms massive baselines. In cross-modal PPG-to-ECG synthesis, it resolves temporal phase drift and dramatically improves the clinical R-peak detection F1-score from 0.37 (baseline) to 0.83. Furthermore, in extreme cross-frequency super-resolution (25Hz to 100Hz), it successfully recovers high-frequency diagnostic landmarks, achieving an unprecedented Pearson correlation of 0.9956. By learning a universal discrete language for biological signals with a fraction of the computational footprint, our approach sets a new trajectory for edge-deployable, multi-modal medical foundation models.

Dynamical Predictive Modelling of Cardiovascular Disease Progression Post-Myocardial Infarction via ECG-Trained Artificial Intelligence Model

Myocardial infarction (MI) is a leading cause of death, and its adverse outcomes are urgent to predict. Yet ECG-based prognostic models underperform because deep learning requires large, labelled datasets, which are scarce in medicine. Foundation models can learn from unlabelled ECGs via selfsupervision, but medically relevant training strategies remain underexplored. We propose a pretrained artificial intelligence model that combines patient-specific temporal information using contrastive learning with supervised multitask heads, then fine-tunes on post-MI outcome prediction. The proposed model outperformed a model trained from scratch (0.794 vs 0.608 AUC) showing that clinically structured ECG modelling improves classification in limited data regimes.

ECG-NAT: A Self-supervised Neighborhood Attention Transformer for Multi-lead Electrocardiogram Classification

Electrocardiogram (ECG) arrhythmia classification remains challenging due to signal variability, noise, limited labeled data, and the difficulty in achieving both accuracy and efficiency in models. While self-supervised learning reduces label dependency, most methods target either global contextual features or local morphological patterns, but rarely implement hierarchical multi-scale feature extraction. ECG signals require architectures that simultaneously capture fine-grained beat-level morphology and broader rhythm-level dependencies with computational efficiency. To overcome this limitation, this paper proposes the Electrocardiogram Neighborhood Attention Transformer (ECG-NAT), a novel self-supervised learning approach tailored for multi-lead ECG classification. Our two-stage approach begins with generative pretraining, using a masked autoencoder to reconstruct partially masked ECG signals across multiple diverse datasets, enabling the model to learn robust, domain-invariant representations from unlabeled data. This is followed by discriminative fine-tuning with a dual-loss function that combines supervised contrastive and cross-entropy losses, aligning representation learning with label prediction. The hierarchical attention mechanism efficiently captures multi-scale temporal features from localized beat morphology to broader rhythm patterns at low computational cost. ECG-NAT achieves robust performance on benchmark datasets, with 88.1\% accuracy using only 1\% labeled data, demonstrating strong efficacy in low-resource settings. The framework combines superior classification performance with computational efficiency, making it practical for real-time ECG diagnosis. The code will be made available upon acceptance at: https://github.com/Mahsagazeran/ECG-NAT.

Neural Surrogate Forward Modelling For Electrocardiology Without Explicit Intracellular Conductivity Tensor

Accurate forward modelling is essential for non-invasive cardiac electrophysiology, particularly in atrial fibrillation, where electrical activation is highly disorganised. Conventional physics-based forward models require explicit specification of intracellular conductivity tensors, which are not directly measurable in clinical practice and introduce structural modelling errors. This proof-of-concept study presents a deep learning approach that learns a direct mapping from left atrial intracellular electrical potentials to far-field ECGs without requiring explicit intracellular conductivity inputs at inference time. Despite training only on 74 subjects, the model achieved an R2 of 0.949 \pm 0.037, highlighting potential to reduce structural uncertainty and improve non-invasive AF assessment.