Prognostic value of digital twin-derived myocardial wall stress in dilated cardiomyopathy
D X Zong, Y Y Gao, W Q Liu, S Leng, C B He, Z Feng, Y F Zhao, A Koh, X D Zhao, R S Tan, Y J Yang, W B Xiao, H J Hu, M S Xu, L ZhongAbstract
Background
Risk stratification in dilated cardiomyopathy (DCM) remains suboptimal, as conventional markers such as left ventricular ejection fraction (LVEF) do not fully capture the complex biomechanical changes underlying ventricular remodeling. Myocardial wall stress is a fundamental driver of disease progression, yet, its clinical application has been hindered by the difficulty of non-invasive measurement in complex cardiac geometries.
Purpose
This study aimed to evaluate the prognostic significance of a digital twin-derived wall stress index (WSI)—which integrates patient-specific geometry, wall thickness, and local curvature—as a novel predictor of adverse outcomes in DCM.
Methods
We retrospectively analyzed 379 patients with DCM (mean age 51±15 years, 73% male, mean LVEF 22±11%). Digital twin technology was used to generate biventricular models to compute global end-systolic WSI. The primary endpoint was a composite of sudden cardiac death or heart transplantation. Prognostic performance was assessed using Cox regression and compared against conventional indices, including LVEF, late gadolinium enhancement (LGE), and ventricular volumes.
Results
During a median 31-month follow-up, 32 patients (8.4%) reached the primary endpoint. Global WSI demonstrated superior prognostic discrimination (C-index: 0.74) compared with left ventricular end-diastolic volume index (LVEDVi, 0.72), end-systolic volume index (0.69), and LVEF (0.60). Univariate analysis showed that a one-standard deviation (SD) increase in WSI was associated with a more than twofold risk of adverse events (hazard ratio [HR]: 2.06; 95% confidence interval [CI]: 1.48–2.87; P<0.001). After adjusting for age, sex, LGE, and LVEDVi, WSI remained a significant independent predictor (adjusted HR: 1.65; 95% CI: 1.08–2.51; P=0.02), providing significant incremental value (delta C-index: +0.05). Kaplan-Meier analysis confirmed significantly lower event-free survival in patients with high WSI (log-rank P<0.001).
Conclusion
Digital twin-derived wall stress provides superior and incremental prognostic value over conventional imaging markers in DCM. These findings suggest that incorporating biomechanical digital twins into clinical workflows can significantly refine risk stratification and support personalized management in patients with DCM.