Deep Survival Analysis from Adult and Pediatric Electrocardiograms: A Multi-center Benchmark Study

Artificial intelligence applied to electrocardiography (AI-ECG) shows potential for mortality prediction, but heterogeneous approaches and private datasets have limited generalizable insights. To address this, we systematically evaluated model design choices across three large cohorts: Beth Israel Deaconess (MIMIC-IV: n = 795,546 ECGs, United States), Telehealth Network of Minas Gerais (Code-15: n = 345,779, Brazil), and Boston Children's Hospital (BCH: n = 255,379, United States). We evaluated models predicting all-cause mortality, comparing horizon-based classification and deep survival methods with neural architectures including convolutional networks and transformers, benchmarking against demographic-only and gradient boosting baselines. Top models performed well (median concordance: Code-15, 0.83; MIMIC-IV, 0.78; BCH, 0.81). Incorporating age and sex improved performance across all datasets. Classifier-Cox models showed site-dependent sensitivity to horizon choice (median Pearson's R: Code-15, 0.35; MIMIC-IV, -0.71; BCH, 0.37). External validation reduced concordance, and in some cases demographic-only models outperformed externally trained AI-ECG models on Code-15. However, models trained on multi-site data outperformed site-specific models by 5-22%. Findings highlight factors for robust AI-ECG deployment: deep survival methods outperformed horizon-based classifiers, demographic covariates improved predictive performance, classifier-based models required site-specific calibration, and cross-cohort training, even between adult and pediatric cohorts, substantially improved performance. These results emphasize the importance of model type, demographics, and training diversity in developing AI-ECG models reliably applicable across populations.