Abstract Introduction Diagnosing prosthetic valve endocarditis poses a significant challenge in daily clinical practice. Accurately identifying these patients is vital due to its treatment implications. Clinical and imaging assessment of suspected cases yields a substantial number of interrelated variables, which can be analyzed through machine learning techniques in order to improve diagnostic accuracy. Feature ranking facilitates identification and interpretability of relevant clinical and imaging variables in this task. Purpose To utilize machine learning feature ranking and modeling in order to improve interpretable identification of patients with prosthetic valve endocarditis. Methods 89 cases defined by the endocarditis team and 173 controls were analyzed. We implemented the SHapley Additive exPlanations (SHAP) method to evaluate feature importance. 5-fold cross-validated Xgboost models were trained and independently tested with additive clinical, echocardiographic and 18F-FDG PET/CT data. Performance was evaluated through confusion matrices, F1-scores and AUCs. These were compared against conventional logistic regression of the Duke Criteria classification. Results Mean age was 59.6 ± 15.7, with 29.7% women. 14 clinical (demographic, laboratory and cultures), 2 echocardiographic, and 5 PET/CT features were included. The XGBoost model trained with all additive features demonstrated an AUC of 0.91±0.1 and outperformed simpler models as well as the Duke classification model (AUC=0.85). The clinical variables alone achieved an AUC of 0.85±0.11, while integration with echocardiography enhanced its performance to 0.90±0.04 (Fig. 1). Feature ranking demonstrated that antibiotic treatment duration, positive blood cultures, valve type, weight and CRP were the most relevant clinical variables, while the presence of vegetation or abscess, and abnormal uptake and uptake focality on PET/CT represented the most relevant imaging variables (Fig. 2). Conclusion Machine learning-based feature ranking and modeling may significantly enhance identification of patients with prosthetic valve endocarditis beyond standard clinical criteria. Feature selection offers interpretable performance in identifying these cases, model testing in clinical decision support may be warranted.Fig. 1:Comparative AUC Analysis.Fig. 2:SHAP feature importance.
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