Deep Learning in Myocarditis: A Novel Approach to Severity Assessment

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Abstract
Background: Myocarditis is a life-threatening disease with significant hemodynamic risks during the acute phase. Although histopathological examination of myocardial biopsy specimens remains the gold standard for diagnosis, there is no established method for objectively quantifying cardiomyocyte damage. We aimed to develop an AI model to evaluate clinical myocarditis severity using comprehensive pathology data. Methods: We retrospectively analyzed 314 patients (1076 samples) who underwent myocardial biopsy from 2002 to 2021 at the National Cerebrovascular Center. Among these patients, 158 were diagnosed with myocarditis based on the Dallas criteria. A Multiple Instance Learning (MIL) model served as a pre-trained classifier to detect myocarditis across whole-slide images. We then constructed two clinical severity-prediction models: (1) a logistic regression model (Model 1) using the density of inflammatory cells per unit area, and (2) a Transformer-based model (Model 2), which processed the top-ranked patches identified by the MIL model to predict clinical severe outcomes. Results: Model 1 achieved an AUROC of 0.809, indicating a robust association between inflammatory cell density and severe myocarditis. In contrast, Model 2, the Transformer-based approach, yielded an AUROC of 0.993 and demonstrated higher accuracy and precision for severity prediction. Attention score visualizations showed that Model 2 captured both inflammatory cell infiltration and additional morphological features. These findings suggest that combining MIL with Transformer architectures enables more comprehensive identification of key histological markers associated with clinical severe disease. Conclusions: Our results highlight that a Transformer-based AI model analyzing whole-slide pathology images can accurately assess clinical myocarditis severity. Moreover, simply quantifying the extent of inflammatory cell infiltration also correlates strongly with clinical outcomes. These methods offer a promising avenue for improving diagnostic precision, guiding treatment decisions, and ultimately enhancing patient management. Future prospective studies are warranted to validate these models in broader clinical settings and facilitate their integration into routine pathological workflows. What is new?: – This is the first study to apply an AI model for the diagnosis and severity assessment of myocarditis. – New evidence shows that inflammatory cell infiltration is related to the severity of myocarditis. – Using information from the entire tissue, not just inflammatory cells, allows for a more accurate assessment of myocarditis severity. What are the clinical implications?: – The use of the AI model allows for an unprecedented histological evaluation of myocarditis severity, which can enhance early diagnosis and intervention strategies. – Rapid and precise assessments of myocarditis severity by the AI model can support clinicians in making timely and appropriate treatment decisions, potentially improving patient outcomes. – The incorporation of this AI model into clinical practice may streamline diagnostic workflows and optimize the allocation of medical resources, enhancing overall patient care.

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