Segmental longitudinal strain (SLS) of the left ventricle (LV) is an important prognostic indicator for evaluating regional LV dysfunction, in particular for diagnosing and managing myocardial ischemia. Current techniques for strain estimation require significant manual intervention and expertise, limiting their efficiency and making them too resource-intensive for monitoring purposes. This study introduces the first automated pipeline, autoStrain, for SLS estimation in transesophageal echocardiography (TEE) using deep learning (DL) methods for motion estimation. We present a comparative analysis of two DL approaches: TeeFlow, based on the RAFT optical flow model for dense frame-to-frame predictions, and TeeTracker, based on the CoTracker point trajectory model for sparse long-sequence predictions. As ground truth motion data from real echocardiographic sequences are hardly accessible, we took advantage of a unique simulation pipeline (SIMUS) to generate a highly realistic synthetic TEE (synTEE) dataset of 80 patients with ground truth myocardial motion to train and evaluate both models. Our evaluation shows that TeeTracker outperforms TeeFlow in accuracy, achieving a mean distance error in motion estimation of 0.65 $\pm$ 0.20 mm on a synTEE test dataset. Clinical validation on 16 patients further demonstrated that SLS estimation with our autoStrain pipeline aligned with clinical references, achieving a mean difference (95% limits of agreement) of 1.09% (-8.90% to 11.09%). Incorporation of simulated ischemia in the synTEE data improved the accuracy of the models in quantifying abnormal deformation. Our findings indicate that integrating AI-driven motion estimation with TEE can significantly enhance the precision and efficiency of cardiac function assessment in clinical settings.

Domain adaptation methods aim to bridge the gap between datasets by enabling knowledge transfer across domains, reducing the need for additional expert annotations. However, many approaches struggle with reliability in the target domain, an issue particularly critical in medical image segmentation, where accuracy and anatomical validity are essential. This challenge is further exacerbated in spatio-temporal data, where the lack of temporal consistency can significantly degrade segmentation quality, and particularly in echocardiography, where the presence of artifacts and noise can further hinder segmentation performance. To address these issues, we present RL4Seg3D, an unsupervised domain adaptation framework for 2D + time echocardiography segmentation. RL4Seg3D integrates novel reward functions and a fusion scheme to enhance key landmark precision in its segmentations while processing full-sized input videos. By leveraging reinforcement learning for image segmentation, our approach improves accuracy, anatomical validity, and temporal consistency while also providing, as a beneficial side effect, a robust uncertainty estimator, which can be used at test time to further enhance segmentation performance. We demonstrate the effectiveness of our framework on over 30,000 echocardiographic videos, showing that it outperforms standard domain adaptation techniques without the need for any labels on the target domain. Code is available at https://github.com/arnaudjudge/RL4Seg3D.

Convolutional neural networks (CNN) have had unprecedented success in medical imaging and, in particular, in medical image segmentation. However, despite the fact that segmentation results are closer than ever to the inter-expert variability, CNNs are not immune to producing anatomically inaccurate segmentations, even when built upon a shape prior. In this paper, we present a framework for producing cardiac image segmentation maps that are guaranteed to respect pre-defined anatomical criteria, while remaining within the inter-expert variability. The idea behind our method is to use a well-trained CNN, have it process cardiac images, identify the anatomically implausible results and warp these results toward the closest anatomically valid cardiac shape. This warping procedure is carried out with a constrained variational autoencoder (cVAE) trained to learn a representation of valid cardiac shapes through a smooth, yet constrained, latent space. With this cVAE, we can project any implausible shape into the cardiac latent space and steer it toward the closest correct shape. We tested our framework on short-axis MRI as well as apical two and four-chamber view ultrasound images, two modalities for which cardiac shapes are drastically different. With our method, CNNs can now produce results that are both within the inter-expert variability and always anatomically plausible without having to rely on a shape prior.