Seeing Beyond the Image: ECG and Anatomical Knowledge-Guided Myocardial Scar Segmentation from Late Gadolinium-Enhanced Images

Abstract: Accurate segmentation of myocardial scar from late gadolinium enhanced (LGE) cardiac MRI is essential for evaluating tissue viability, yet remains challenging due to variable contrast and imaging artifacts. Electrocardiogram (ECG) signals provide complementary physiological information, as conduction abnormalities can help localize or suggest scarred myocardial regions. In this work, we propose a novel multimodal framework that integrates ECG-derived electrophysiological information with anatomical priors from the AHA-17 atlas for physiologically consistent LGE-based scar segmentation. As ECGs and LGE-MRIs are not acquired simultaneously, we introduce a Temporal Aware Feature Fusion (TAFF) mechanism that dynamically weights and fuses features based on their acquisition time difference. Our method was evaluated on a clinical dataset and achieved substantial gains over the state-of-the-art image-only baseline (nnU-Net), increasing the average Dice score for scars from 0.6149 to 0.8463 and achieving high performance in both precision (0.9115) and sensitivity (0.9043). These results show that integrating physiological and anatomical knowledge allows the model to "see beyond the image", setting a new direction for robust and physiologically grounded cardiac scar segmentation.