Calibration and validation strategy for electromechanical cardiac digital twins

State-of-the-art cardiac electromechanical modelling and simulation form the basis for recent developments in cardiac Digital Twin technologies. However, a comprehensive evaluation of electromechanical models at cellular, tissue, and organ level has yet to be performed that addresses both ECG and pressure-volume biomarkers. Such an evaluation would build credibility for applications of cardiac Digital Twins in clinical research and therapy development. We aimed to follow ASME V&V40 standards for calibration, validation, and sensitivity analysis of ventricular electromechanical models under healthy conditions, to progress towards the Digital Twin vision. We performed a multi-scaled review of ventricular electromechanics and compiled a dataset for calibration and validation incorporating ECG, pressure-volume, displacement, and strain biomarkers. When applied to a biventricular multiscale model, we achieved healthy calibrated values for the QRS duration (89 ms), QT interval (360 ms), left ventricular ejection fraction (LVEF) (51 %), peak systolic pressure (14 kPa), end diastolic (105 mL) and end systolic volumes (51 mL), peak ejection flow rate (180 mL/ms). Model validation was performed by comparison to displacement and strain biomarkers including systolic atrioventricular plane displacement (1.5 cm), systolic fibre strain (−0.18) and longitudinal strain (−0.15). Sensitivity analysis of model parameters at cellular and ventricular scales was also performed to inform model calibration and as a first step towards uncertainty quantification. We quantified the effects of variability in ionic conductance, mechanical stiffness, cross-bridge cycling dynamics, and systemic circulation on action potential and active tension dynamics at the cellular scale, and on ECG, pressure-volume, displacement, and strain biomarkers at the ventricular scale. Simulations showed that the relationship between healthy LVEF and T wave biomarkers was primarily underpinned by variability in L-type calcium channel conductance and SERCA activity through multi-scale effects. In this study, we provide a systematic framework for credibility assessment of cardiac electromechanical models based on both ECG and mechanical biomarkers, as a foundational step towards the cardiac Digital Twin vision.