# Domain-Adapted Fine-Tuning of ECG Foundation Models for Multi-Label Structural Heart Disease Screening

arXiv: https://arxiv.org/abs/2604.23385 · HTML: https://mlsanity.com/paper/2604.23385/

## Key facts

- Cited by 1 papers in the map (data through 14 Oct 2026).
- Builds on 9 of its 21 references that are in the map.
- First posted on arXiv 25 Apr 2026.

## Builds on (most cited first, 9 of 9)

- [Deep Residual Learning for Image Recognition](https://mlsanity.com/paper/1512.03385/) (2015)
- [XGBoost: A Scalable Tree Boosting System](https://mlsanity.com/paper/1603.02754/) (2016)
- [wav2vec 2.0: A Framework for Self-Supervised Learning of Speech Representations](https://mlsanity.com/paper/2006.11477/) (2020)
- [Optuna: A Next-generation Hyperparameter Optimization Framework](https://mlsanity.com/paper/1907.10902/) (2019)
- [CLOCS: Contrastive Learning of Cardiac Signals Across Space, Time, and Patients](https://mlsanity.com/paper/2005.13249/) (2020)
- [Automatic diagnosis of the 12-lead ECG using a deep neural network](https://mlsanity.com/paper/1904.01949/) (2019)
- [Deep Learning for ECG Analysis: Benchmarks and Insights from PTB-XL](https://mlsanity.com/paper/2004.13701/) (2020)
- [ECG-FM: An Open Electrocardiogram Foundation Model](https://mlsanity.com/paper/2408.05178/) (2024)
- [An Electrocardiogram Foundation Model Built on over 10 Million Recordings with External Evaluation across Multiple Domains](https://mlsanity.com/paper/2410.04133/) (2024)

## Built on by (most cited first, 1 of 1)

- [Pretraining Strategies and Scaling for ECG Foundation Models: A Systematic Study](https://mlsanity.com/paper/2605.12241/) (2026)

## Abstract (arXiv)

Transthoracic echocardiography is the reference standard for confirming structural heart disease (SHD), but first-line screening is limited by cost, workflow burden, and specialist availability. We evaluated whether open pretrained electrocardiogram (ECG) foundation models can support echo-confirmed multi-label SHD detection using the public EchoNext Mini-Model benchmark. Six echocardiography-derived abnormalities were targeted: reduced left ventricular ejection fraction, increased left ventricular wall thickness, aortic stenosis, mitral regurgitation, tricuspid regurgitation, and right ventricular systolic dysfunction. Under a common pipeline, we compared engineered ECG features with gradient boosting, end-to-end waveform learning from scratch, and transfer from open ECG foundation models. We then applied in-domain self-supervised adaptation of an ECG foundation model (ECG-FM) on EchoNext waveforms followed by selective supervised fine-tuning, and evaluated trade-offs between discrimination and adaptation cost. Adapted ECG-FM models achieved the best overall performance: peak macro-AUROC 0.8509 and macro-AUPRC 0.4297, while a parameter-efficient operating point preserved AUROC (0.8501) and attained the highest fixed-threshold macro-F1 0.3691. Late fusion with covariates did not improve threshold-independent discrimination, and evaluated LoRA, alternative backbones, and mixture-of-foundations strategies did not surpass the best adapted single-backbone models. These results indicate that for ECG-based case finding and echocardiography triage, combining target-domain self-supervised adaptation with selective supervised updating of a pretrained ECG backbone is the most effective transfer strategy.