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01.
arXiv (quant-ph) 2026-06-12

Quantum Network Routing based on Surface Code Error Correction

arXiv:2606.12781v1 Announce Type: new Abstract: Quantum networks encounter unavoidable channel noises and erasure errors, presenting a huge obstacle in designing protocols that attain both high reliability and efficiency. Typically, quantum networks fall into two categories: those utilize quantum entanglements for quantum teleportation, and those directly transfer the actual quantum messages. In this paper, we present SurfNet, a quantum network that inherits the main advantages from both categories. It employs surface codes as logical qubits for encoding messages, and utilizes two parallel communication channels to fault-tolerantly transfer each surface code in a modular manner. Our approach of using surface codes can timely correct both operational and photon loss errors within the network, and the integration of the two channels within the network can greatly improve network throughput. For the implementation of SurfNet, we propose a novel network architecture, designed to better integrate surface codes into quantum networks. We also propose a novel error correction decoder, designed to fully utilize the modular characteristic of surface codes within our network. Simulation results demonstrate that SurfNet with its decoder significantly enhances the communication fidelity within quantum networks.

02.
arXiv (CS.AI) 2026-06-11

ConsistencyPlanner: Real-time Planning with Fast-Sampling Consistency Models

arXiv:2606.11569v1 Announce Type: cross Abstract: Closed-loop planning in complex, real-world driving scenarios presents a critical challenge for autonomous driving systems. While traditional rule-based methods are interpretable, their predefined heuristics lack the adaptability for dynamic traffic environments. Learning-based approaches have shown considerable promise. Conversely, learning-based approaches, despite their promise, struggle to balance the modeling diverse and multimodal driving behaviors and real-time planning, often leading to indecisive or unsafe actions. To address this limitation, we propose Consistency Planner, a real-time planning framework with fast-sampling consistency models. Our approach is built upon two key technical contributions. Efficient Multimodal Sampling: We employ fast-sampling consistency models to generate a diverse set of plausible future trajectories. This enables efficient, real-time exploration of multimodal actions, overcoming the computational bottlenecks of previous iterative generative methods. Heterogeneous Feature Fusion: We introduce an attention-enhanced decoder that dynamically integrates heterogeneous input features (including scene feature and action token) into a cohesive representation for robust planning. Extensive evaluation in the Waymax simulator demonstrates superior performance in safety metrics compared to existing methods, with particularly strong results in challenging dynamic scenarios.

03.
arXiv (quant-ph) 2026-06-15

Resolving the Edge of a Quantum Pyramid

arXiv:2606.14698v1 Announce Type: new Abstract: Standing on the shoulders of giants, we resolve the quantum pyramids conjecture, confirming the globally information-optimal measurement for an ensemble of equiangular equiprobable pure states, as conjectured by Englert and \v{R}eháček (arXiv:0905.0510). We do so by proving the remaining entropy inequalities of Holevo and Utkin (arXiv:2506.06700), which certify optimality for obtuse and flat pyramids. For obtuse pyramids, our key contribution is a rigorous proof that local minimizers of the corresponding entropy inequality cannot have three distinct coordinate values. We show that eliminating this family can be reduced to a neat algebraic reciprocal inequality relating branches of the Lambert $W$ function, which may be of independent interest. For flat pyramids, we prove a tight $\ell^p$ inequality for zero-sum vectors that was recently conjectured, proved analytically in dimension $d=3$, and computationally verified for $d\leq 200$ by Holevo and Utkin (arXiv:2603.24017). We prove this bound for all $d\geq 2$ via a technique in symmetric inequalities known as the equal variables method.

04.
arXiv (CS.CL) 2026-06-16

PACUTE: Phonology-, Affix-, and Character-level Understanding of Tokens for Filipino

Large language models (LLMs) process text as sequences of subword tokens, which can obscure the character-level and morphological structure that underlies word formation. This limitation is most acute for languages with non-concatenative morphology, where standard tokenizers systematically misalign token boundaries with morpheme boundaries. We introduce PACUTE, a diagnostic benchmark of 4,600 tasks designed to evaluate morphological understanding in Filipino, a language characterized by productive infixation, reduplication, and diacritic-driven lexical distinctions that are typically absent from written text. PACUTE includes a hierarchical diagnostic framework of six compositional levels that localizes where morphological understanding breaks down. Evaluating open-weight LLMs and frontier commercial models, we find that open-weight models perform near chance on morpheme decomposition regardless of scale. Frontier models perform much better, often recovering individual affixes under contains-match scoring, but remain far below their character-level ceilings on compositional tasks of morpheme transformations and syllabification. These results identify productive morphological composition, rather than character access alone, as the persistent bottleneck for Filipino word-structure understanding.

06.
arXiv (math.PR) 2026-06-18

Evolution of Conditional Entropy for Diffusion Dynamics on Graphs

arXiv:2510.19441v2 Announce Type: replace-cross Abstract: The modeling of diffusion processes on graphs is the basis for many network science and machine learning approaches. Entropic measures of network-based diffusion have recently been employed to investigate the reversibility of these processes and the diversity of the modeled systems. While results about their steady state are well-known, very few exact results about their finite-time evolution exist. Here, we introduce the conditional entropy of heat diffusion in graphs, and outline a mathematical framework that contextualizes diffusion and conditional entropy within the theories of continuous-time Markov chains and information theory. In particular, we highlight that this entropic measure satisfies an information-theoretical version of the second law of thermodynamics, thereby providing a parallelism between diffusion dynamics on networks and their physical counterparts. Furthermore, we obtain explicit results for its evolution on complete, path, and circulant graphs, as well as a mean-field approximation for Erdös-Rényi graphs. We also obtain asymptotic results for general networks and provide bounds for the evolution of conditional entropy. Finally, we experimentally demonstrate several properties of conditional entropy for diffusion over random graphs, such as the Watts-Strogatz model.

07.
arXiv (CS.AI) 2026-06-12

Prism: Cost-Efficient Multi-LLM Serving via GPU Memory Ballooning

arXiv:2505.04021v3 Announce Type: replace-cross Abstract: Inference providers must maintain availability for many LLMs, including low-volume but essential models, making resource efficiency increasingly important as token prices fall. Analysis of production traces reveals a dynamic bursty-group pattern in which sets of models become active together and shift over time; existing space- and time-sharing approaches lack principled mechanisms to adapt to this variability, forcing trade-offs between SLO adherence and efficiency. We observe that elastic memory allocation can unify spatial and temporal sharing. Based on this insight, we have developed Prism, a memory-centric LLM co-serving framework that applies memory ballooning to reclaim memory across models and support both forms of sharing under a single scheme. Prism's balloon driver, referred to as kvcached, has been open-sourced at https://github.com/ovg-project/kvcached, and deployed in production environments across 10K+ GPUs.

08.
arXiv (CS.LG) 2026-06-15

Shuttling Compiler for Trapped-Ion Quantum Computers Based on Large Language Models

arXiv:2512.18021v3 Announce Type: replace-cross Abstract: We present the first shuttling compiler based on large language models (LLMs) for trapped-ion quantum computers, where qubits are shuttled between segments for gate execution and qubit storage. We fine-tune pre-trained LLMs on examples from linear and branched one-dimensional shuttling architectures. Thus, we obtain a layout-independent compilation strategy that learns the required shuttling operations directly from data. Using benchmark circuits with up to 16 qubits, such fine-tuned LLMs can now generate valid schedules for shuttling architectures. Notably, we also obtain a valid schedule for a previously unseen four-way junction layout. This demonstrates that trained LLMs can generalize to layouts not encountered during training. For various architectures, LLM-based schedules improve upon state-of-the-art baseline compiler results, reducing the shuttling effort by up to 15%.

09.
arXiv (CS.CL) 2026-06-16

SkillsVote: Lifecycle Governance of Agent Skills from Collection, Recommendation to Evolution

Long-horizon LLM agents generate traces that could become reusable experience, but raw trajectories are noisy, local, and hard to govern. Agent Skills offer a structured artifact for combining procedural guidance, executable resources, and applicability boundaries. Yet open skill ecosystems contain redundant, uneven, environment-sensitive artifacts, and indiscriminate updates can pollute future context. We present SkillsVote, a lifecycle-governance framework for Agent Skills across collection, recommendation, attribution, and evolution. SkillsVote profiles a million-scale open source corpus for environment requirements, quality, and verifiability, and synthesizes tasks for verifiable skills. Before execution, it performs agentic library search over structured skill folders to expose instructional context. After execution, it decomposes trajectories into skill-linked subtasks, attributes outcomes to skill-guided execution, agent exploration, environment, and result signals, and admits only successful reusable discoveries to evidence-gated updates. Experiments on Terminal-Bench 2.0 and SWE-Bench Pro show that SkillsVote improves agent performance on challenging agentic coding benchmarks. The gains arise from two complementary pathways: online evolution over task streams at test time and offline transfer via frozen libraries built from either historical trajectories or curated open source skills.

10.
arXiv (CS.AI) 2026-06-19

Mitigating Legibility Tax with Decoupled Prover-Verifier Games

arXiv:2602.23248v2 Announce Type: replace Abstract: As large language models become increasingly capable, it is critical that their outputs can be easily checked by less capable systems. Prover-verifier games can be used to improve checkability of model outputs, but display a degradation in accuracy compared to a baseline trained only to maximize correctness – a phenonemon named legibility tax. We propose a solution by decoupling the correctness from the checkability condition and instead training a "translator" model that turns a fixed solver model's solution into a checkable form. This allows us to first train the solver to maximize correctness, and then train the translator to translate the solver into a checkable form while retaining the solver's answer. To accommodate this new objective of translation, we formulate a decoupled prover-verifier game (DPVG) where the equilibria correspond to faithful and checkable translators.

11.
arXiv (CS.AI) 2026-06-16

PH-KAN: Port-Hamiltonian Kolmogorov-Arnold Network

arXiv:2606.14708v1 Announce Type: cross Abstract: Data-driven machine learning approaches have become increasingly attractive for nonlinear system identification, but standard models often fail to preserve the underlying physical structure and remain difficult to interpret, especially when no analytical model is available. In this context, port-Hamiltonian (pH) models provide a natural physics-informed representation. However, when these models are parameterized with standard multilayer perceptrons (MLPs), the learned constitutive components often remain poorly interpretable. In this paper, we propose a structure-preserving identification framework for nonlinear port-Hamiltonian systems based on Kolmogorov-Arnold Networks (KANs). The proposed PH-KAN model parameterizes the interconnection matrix, dissipation matrix, Hamiltonian, and input mapping using dedicated KAN blocks, while enforcing the port-Hamiltonian constraints by construction. This yields constitutive representations in which the nonlinear functions defining the identified pH components can be explicitly inspected, leading to a more interpretable model than with standard MLP-based parameterizations.

12.
arXiv (CS.CL) 2026-06-16

Re-feeding Is Not Replaying: Measuring Replay Noise in Counterfactual Token-Credit Estimation

Authors:

Per-token counterfactual credit estimation asks which token in a language-model rollout caused the final answer to be right or wrong: cut the transcript at a pivot, substitute an alternative token, replay continuations, and compare outcomes. Published methods re-feed the transcript prefix as a fresh prompt, assuming this reproduces the state the model passed through during generation. We measure what that assumption costs on a stock inference engine, with a three-pass design: continuations resumed from the verified decode-time KV state, an identical second exact pass (a replica noise floor), and a re-feed pass. Across six configurations and three models (including a GRPO-trained checkpoint), at low-margin decision tokens, re-feeding changes the credit estimate at rates 14-28 percentage points above the replica floor (7-21pp under a treatment-independent conditioning; problem-clustered t = 2.9-6.4). Most changes are zero-boundary crossings of the quantized estimator rather than polarity reversals, and the perturbation is consistent with mean-zero, so averaged quantities are largely safe; but selection is not: a critical-token set chosen by thresholding $|\hat{A}_t|$ under re-feed overlaps the exact-resume selection at Jaccard 0.34-0.90, versus a 0.63-0.96 replica ceiling. A causal confirmation closes the loop: under vLLM's batch-invariant kernels all three passes are identical on every measured channel, with both disagreement rates exactly zero. Replica passes themselves disagree on 9-23% of eligible estimates: single-sample credit measurements at decision tokens are unreliable under any replay. Settings were fixed in advance; exact-pass cache hits in the second campaign are instrumented (100% hit rate, 3,434 pivots); total compute was under 10 USD. We recommend that counterfactual credit studies resume decoder state or use batch-invariant kernels, and report a replica floor.

13.
arXiv (CS.CV) 2026-06-12

A Multi-Modal Framework with Cross-Subject Pseudo-Labeling and Semantic Alignment for Micro-Gesture Recognition

Micro-gestures (MGs) are spontaneous and subtle body movements that frequently convey hidden human emotions. Recognizing MGs in untrimmed videos remains highly challenging due to their extremely low signal-to-noise ratio, severe long-tailed class distribution, and the inherent domain shift encountered in cross-subject evaluation scenarios. In this paper, we propose a comprehensive multi-modal framework for Track 1 of the 4th MiGA-IJCAI Challenge. To capture fine-grained representations, we design a saliency-guided multi-modal extraction pipeline integrating 68-keypoint skeleton joint coordinates, 3D heatmap volumes, and high-resolution RGB visual features. We introduce a gentle square-root smoothed weighting mechanism paired with an Orthogonal Semantic Embedding Loss to protect tail classes without compromising overall recognition capabilities. More importantly, to bridge the cross-subject generalization gap, we propose a Cross-Modal Pseudo-Labeling (CMPL) strategy for unsupervised domain adaptation, which significantly boosts single-modal robustness. A temperature-scaled soft-voting mechanism is finally utilized to alleviate overconfidence during late fusion. Extensive experiments demonstrate that our framework achieves a competitive F1-score of 68.13\%, securing the 4th place.

14.
arXiv (CS.CL) 2026-06-17

Reading between the Lines: Leveraging Large Language Models for Global Dementia and Depression Assessment from Clinical Interviews

Dementia and depression are the most prevalent neuropsychiatric disorders in geriatric populations, and their overlapping symptoms pose major challenges for differential diagnosis. In this study, we investigate open-weights Large Language Models (LLMs) for predicting dementia and depression severity from speech samples collected during standardized history taking interviews with 154 German-speaking subjects. We introduce an observer-based Global Depression Scale (GDS-D) aligned with the established Global Deterioration Scale (GDS), enabling parallel global staging of affective and cognitive symptoms. We compare three LLMs (Mistral 3.1, DeepHermes, Qwen3) in two settings: (1) zero-shot prediction and (2) LLM-based feature extraction for Support Vector Regression, using human and pause-enriched transcripts. Results show that LLMs effectively predict depression severity in zero-shot settings (best MAE of 0.60), while dementia assessment benefits substantially from structured feature extraction (best MAE of 0.78), reducing errors by up to 35% over zero-shot baselines. Pause-enriched transcripts achieve competitive performance with human transcriptions, demonstrating the viability of fully automatic screening pipelines for differential neuropsychiatric assessment.

15.
arXiv (CS.CL) 2026-06-16

Mechanistic Analysis of Catastrophic Forgetting in Large Language Models During Continual Fine-tuning

Sequential fine-tuning of Large Language Models (LLMs) adaptation to target tasks often triggers catastrophic forgetting, where the acquisition of novel target skills degrades ancestral capabilities. This paper presents a systematic comparative study of catastrophic forgetting across twenty premier models representing the state-of-the-art in mid-2026. We categorize our investigation into two primary research lines: (i) a behavioral and semantic output drift analysis of ten leading closed-source models (including Claude Fable 5, GPT-5.5 High, and Gemini 3.5 Flash), and (ii) a deep mechanistic interpretation of ten prominent open-weight architectures (such as DeepSeek-V4-Pro, Llama 4 Maverick, and Qwen 3.6-27B). Through weight-space trajectory tracking, Centered Kernel Alignment (CKA), and routing gate drift calculations in Mixture-of-Experts (MoE) layers, we localize the neural circuits highly susceptible to parameter overwriting. Our findings indicate that early-layer attention heads exhibit systemic entropic dispersion, while mid-to-deep feed-forward networks (or sparse expert blocks) suffer localized representation collapse. Informed by these insights, we introduce Low-Rank Circuit Projection (LRCP), a subspace-regularized training intervention. Empirical evaluations show that LRCP successfully mitigates up to 94.2% of ancestral capabilities in open-weight configurations and matches the adaptation velocity of standard PEFT baselines.

16.
arXiv (CS.LG) 2026-06-18

Acceleration of an algebraic multigrid pressure solver using graph neural networks

arXiv:2606.19251v1 Announce Type: cross Abstract: Solving the pressure-Poisson equation remains the primary computational bottleneck in incompressible unstructured flow solvers primarily due to the inherent sensitivity of traditional linear solvers to mesh irregularities. This work introduces a data-driven algebraic multigrid (AMG) smoother that uses a modified graph convolutional isomorphism network (GCIN). The graph neural network predicts optimal polynomial coefficients to construct a sparse pseudo-inverse operator across diverse grid topologies. The coefficients are optimized to reduce the residual after each V-cycle iteration. By directly capturing the algebraic structure of the system from the sparse coefficient matrix, the proposed method maintains the solver's linearity while adapting to local anisotropies in unstructured grids. Our framework demonstrates significant performance gains by reducing the number of V-cycles required for a given tolerance and delivering wall-clock speedups from 4% to 37% across diverse benchmarks. Notably, the model exhibits robust generalization by maintaining efficiency on meshes up to 128 times larger than those seen in training, and by accelerating the solver's convergence on unseen industry-relevant problems such as the AirfRANS dataset.

17.
arXiv (CS.CL) 2026-06-15

Large Language Model Agents Are Not Always Faithful Self-Evolvers

Self-evolving large language model (LLM) agents continually improve by accumulating and reusing past experience, yet it remains unclear whether they faithfully rely on that experience to guide their behavior. We present the first systematic investigation of experience faithfulness, the causal dependence of an agent's decisions on the experience it is given, in self-evolving LLM agents. Using controlled causal interventions on both raw and condensed forms of experience, we comprehensively evaluate four representative frameworks across 13 LLM backbones and 9 environments. Our analysis uncovers a striking asymmetry: while agents consistently depend on raw experience, they often disregard or misinterpret condensed experience, even when it is the only experience provided. This gap persists across single- and multi-agent configurations and across backbone scales. We trace its underlying causes to three factors: the semantic limitations of condensed content, internal processing biases that suppress experience, and task regimes where pretrained priors already suffice. These findings challenge prevailing assumptions about self-evolving methods and underscore the need for more faithful and reliable approaches to experience integration.

19.
arXiv (CS.AI) 2026-06-11

Quantized Stochastic Primal-Dual Methods for Distributed Optimization under Relaxed Global Geometry

arXiv:2606.11339v1 Announce Type: cross Abstract: We study distributed optimization with stochastic gradients and finite-bit communication modeled by random (unbiased) quantization. We propose q-PDGD, a quantized stochastic primal-dual method, and analyze it under relaxed global geometry. Under restricted secant inequality (RSI), a constant step-size yields linear contraction to an explicit neighborhood determined by gradient noise, quantization distortion, and network connectivity, while a diminishing step-size achieves O(1/k) convergence without shared-minimizer assumptions. Under Polyak-Lojasiewicz (PL) inequality, we obtain linear-to-neighborhood convergence in the same stochastic quantized setting. Our results match the best-known centralized stochastic rates in oracle complexity, and are supported by experiments demonstrating the predicted tradeoffs between quantization level, step-size choice, and graph structure.

20.
arXiv (CS.CV) 2026-06-16

Scribby: A Multi-Level LLM Framework for Semantic Video Analysis

As video content continues to expand across educational platforms, recorded lectures, and live-streamed entertainment, the need for efficient and structured analysis of long-form footage has increased [1]. Although many existing AI programs provide high-level video summaries based on AI-generated transcripts [2,3,4,5], these approaches are often limited to coarse overviews and lack detailed analysis of a video's structure, thematic progression, and semantic relationships, all of which are required for comprehensive video analysis. This paper proposes an LLM-based video summarization framework that balances macro-level comprehension with micro-level semantic analysis [6,12,13]. The first stage of the process indexes the video at a micro level by (1) analyzing the full transcript, (2) analyzing individual transcript sentences, and (3) grouping these sentences by semantic similarity using an LLM as a judge [6,13]. Contextual continuity is retained during sentence-level processing by incorporating both the global transcript analysis and adjacent sentence information into each evaluation prompt. This framework establishes a foundation for video analysis tools that visualize semantic chunking and semantic matching through relevance-based heatmaps. Limitations and future expansions of the framework are also discussed.

21.
arXiv (CS.LG) 2026-06-11

Projected random forests and conformal prediction of circular data

arXiv:2410.24145v3 Announce Type: replace-cross Abstract: We apply conformal prediction techniques to regression problems with circular responses, producing prediction sets with adaptive arc length and finite-sample coverage guarantees for any circular predictive model under the assumption of data exchangeability. Leveraging the high performance of existing predictive models designed for linear responses, we analyze a general projection procedure that converts any linear-response regression model into one suitable for circular responses. When random forests are used as base models in this projection procedure, we leverage the random forest out-of-bag mechanism to eliminate the need for a separate calibration sample in the construction of prediction sets. On synthetic and real datasets, the resulting projected random forest model produces more efficient out-of-bag conformal prediction sets, with shorter median arc length, than the split conformal prediction sets generated by two existing alternative models.

22.
arXiv (CS.CL) 2026-06-11

RedAct: Redacting Agent Capability Traces for Procedural Skill Protection

Users rely on execution traces to observe agent behavior, diagnose failures, and ensure accountability. These traces contain rich procedural detail, including tool invocations, intermediate decisions, and error-recovery logic. Yet this detail can expose private procedural skills, allowing downstream methods to recover key formulas, thresholds, and strategies without access to model weights or skill files. To quantify this risk and evaluate protection, we construct \textsc{CapTraceBench}, a benchmark of 75 specialized long-horizon tasks and 154 curated skills across seven domains. We also introduce \textsc{RedAct} https://github.com/XuShuwenn/RedAct, a protected trace release framework that localizes protected key information, rewrites traces while preserving verifier-critical evidence, and embeds behavioral watermarks for downstream provenance analysis. Across representative trace reuse methods, \textsc{RedAct} reduces normalized skill transfer (NST) from 44.7–67.1\% on raw traces to below the no-skill baseline, while preserving audit evidence. Its standalone behavioral watermarks reach 93.6–100.0\% true detection with a false alarm rate of at most 1.9\%. These results frame public agent traces as security interfaces and show that selective redaction can reduce procedural capability leakage without removing audit evidence.

23.
arXiv (CS.CL) 2026-06-17

When Multiple Scripts Matter: Evaluating ASR in Clinical Settings

Automatic speech recognition (ASR) in non-English clinical settings is challenged by multiscript variability, where the same term may appear in multiple valid orthographic forms. Conventional string-matching evaluation metrics often underestimate ASR performance by treating orthographic variants as errors. To address this issue, we introduce MultiClin, a clinical ASR benchmark designed to evaluate robustness to multiscript variability. Experiments across diverse ASR models show that multiscript-aware evaluation provides a fairer assessment of recognition quality than conventional single-reference evaluation. We further investigate the impact of script consistency during training and find that inconsistent script mappings increase orthographic uncertainty and hinder model convergence, with a balanced 50% mapping ratio producing the highest entropy. In contrast, script unification consistently yields the best ASR performance. Our dataset and code are publicly available at: https://github.com/aitrics-ronaldo/Interspeech_MultiClin.

24.
arXiv (CS.CL) 2026-06-16

AuAu: A Benchmark for Auditing Authoritarian Alignment in Large Language Models

The worldwide surge of authoritarianism, combined with the increasing central role in users' everyday lives, raises the question of to what extent specific models exhibit or promote authoritarian attitudes and characteristics. We introduce AuAu, a comprehensive benchmark that aims to assess the risk of LLMs generating responses with authoritarian tendencies. This benchmark combines three evaluation approaches: (i) psychometric questions from an extensive pool of 15 human validated instruments; (ii) contextual behavior vignettes probing intended actions in concrete situations; and (iii) responses to realistic user prompts. Unlike prior work, AuAu evaluates not only a general closeness towards authoritarianism but also the established sub-concepts Authoritarian Aggression, Authoritarian Submission, and Conventionalism. Evaluating 17 models from China, the EU, Russia, and the USA, we find that all tested models exhibit substantial authoritarian response rates under the psychometric evaluation, though rates drop significantly in increasingly more realistic downstream task. We further find that an authoritarian system prompt easily manipulates 15 out of 17 models to promote increased authoritarianism. Our results underscore the need for continued, systematic auditing of LLM-based AI systems to detect and ultimately mitigate undesired authoritarian tendencies in generated output. Our code and data are available at: https://github.com/andreaseinwiller/AuAu

25.
medRxiv (Medicine) 2026-06-10

Resolving Diagnostic Discordance in Group 2 Pulmonary Hypertension Through Staged Physiologic Testing: Insights From PVDOMICS

Background World Symposium on Pulmonary Hypertension (WSPH) Group 2 pulmonary hypertension (PH) is a clinically integrated phenotype attributed to left heart disease, whereas pre- versus post-capillary classification is operationalized primarily by pulmonary capillary wedge pressure (PCWP). Although current recommendations emphasize contextual interpretation and provocative testing for intermediate PCWP values, the relationship between PCWP-based classification and underlying phenotype has not been systematically evaluated. We aim to quantify phenotype-hemodynamic discordance across the PCWP spectrum and evaluate a staged physiology-guided framework incorporating inhaled nitric oxide (iNO), ventricular geometry, and provocative testing. Methods We studied 1,032 participants from the NHLBI-sponsored PVDOMICS cohort with multidisciplinary adjudicated phenotypes integrating clinical, imaging, physiologic, and hemodynamic data. Stage-specific PCWP thresholds classified pre- versus post-capillary physiology at rest, during iNO, and during provocation (fluid challenge or invasive cardiopulmonary exercise testing [iCPET]). Echocardiographic right ventricular-to-left ventricular (RV/LV) ratio was evaluated as a marker of ventricular interdependence. Restricted cubic spline and staged concordance analyses defined certainty-based PCWP ranges and incremental diagnostic yield. Results Adjudicated Group 2 phenotype was present in 37.0% of participants. Resting PCWP demonstrated good discrimination (AUC 0.86), but substantial bidirectional phenotype-hemodynamic discordance persisted across intermediate PCWP ranges. At a resting PCWP of 12 mmHg, 25% of participants classified as pre-capillary had adjudicated Group 2 PH, whereas at 18 mmHg, 35% classified as post-capillary remained discordant non-Group 2. Concordance did not approach 90% until PCWP values were 24 mmHg. Dynamic testing incrementally improved concordance within these overlap zones. Nearly half of adjudicated Group 2 PH participants (46.5%) were not identified by resting PCWP alone; incorporation of iNO and provocative testing increased cumulative Group 2 identification by 63.4% and improved sensitivity from 79.9% to 83.7%. Model discrimination improved from an AUC of 0.863 to 0.908 (likelihood-ratio P