Francisco Soto, MD, MS, MBA

Hemodynamics and Right Heart Cath tweetorials collection. All in one place! Threads: 1. PA Catheter (PAC 101). The basics 2. Waveform recognition (PAC in ICU) 3. Quality control: 🔑troubleshooting before you use the data 4. Preventing the most dreadful PAC complication

"I still struggle with cardiopulmonary hemodynamics in pulmonary hypertension." 😞 If this is you, answer these 2 questions: 1. Are you coming to ATS 2026 in Orlando, FL? 2. Will you be there by Saturday morning (5/16/26)? If you answer YES to both, join us for the Saturday, 12-4 PM Post Graduate course: 🔥 PG19 Wave Goodbye to Confusion: Right Heart Catheterization and Waveform Interpretation 🔹 Outstanding talks 🔹 Lots of practical case-based discussions and breakout sessions 🔹 An amazing group of experts from the cardiopulmonary fields But hurry up. Attendance is limited! Registration link 👇 ats2026.d365.events/education/sess… @atscommunity @ATS_PC #ATS2026

Colleague: “Pulmonary vascular disease is changing too fast. I can’t keep up anymore.😞😞 Wish there was a meeting in the NY area for me to catch up...” Me: “Wait! Did you just say, New York?” Colleague: “Yes. Why?” Me: “Say no more. You’re in luck! ✅✅ Next Saturday, April 18, the PVD symposium by @NorthwellHealth and @TempleHealth brings together key PVD experts to share updates. I'll be helping with two talks." You'll learn about: 🔹 PE risk stratification 🔹 Echocardiography in PE 🔹 The 2026 multi-society PE guidelines 🔹 PE treatment (invasive and non-invasive) 🔹 Post PE syndrome 🔹 PH and PAH classification 🔹 PAH risk stratification and treatment 🔹 Imaging in PH 🔹 Group 2 PH (including sotatercept/CADENCE insights) 🔹 And more! Colleague: “Wow. This thread somehow sounds like a cheap infomercial, but I’m in. Where do I sign up?” Me: “Check the link below👇to sign up and see the brochure. And yes. I am counting on your applause.” 😏 cmetracker.net/NORTHWELL/Publ… 🔥Great activity for: 🔸Physicians 🔸Fellows/Residents 🔸Medical students (Free!!) 🔸Nurse practitioners 🔸Physician Assistants 🔸Nurses 🔸Other health care team members interested in PVD Course directors: @ParthRali @mina_bushra @chadkligermd @ScheinerMD #medtwitter *No virtual attendance or recorded sessions options

@redraiderpulmcc 🙏🏻🤗

@FSotoMD Excellent topic and thread my good friend @FSotoMD

Key question (and answer) for what to do if you cannot get a wedge 👇🏻 It helps in many cases…

Great question. 🗝️Answer 👇👇 My suggestion IF: 1. U don't know how to get a wedge (or don't feel comfortable obtaining one at bedside), OR, 2. You CAN NOT get it despite trying Look at the very initial RHC numbers. Was there an initial accurate: ✅Wedge/PAP comparison (figure 1 below; wedge to PA transition in red) where: 🔹Wedge was either ~PADP, or, 🔹Just 1-2 points lower, OR, ✅ PADP matched LVEDP numbers (figure 2 below; simultaneous PADP on LVEDP) ------------------ If so, THEN: ✅You can use your PADP as a surrogate for your wedge. Meaning, in this case, PADP of 22 suggests wedge is ~22. OK to give the Lasix dose 🛑✋The limitation for using PADP as wedge surrogate is patients with precapillary PH. Such as: PADP of 22 with a wedge of 5. PADP is higher because of precapillary constriction In those cases, PADP can NOT be used as wedge surrogate. Hope it helps..... #medtwitter

@FSotoMD What if you don’t have access to the wedge? Would you stop it?

You walk into the ICU 🏥. 100 mg IV Lasix about to be 💉. PA 51/22 (mean 32) Wedge 30 Do you 🛑✋ it? 7 practical ✅ I use to whether I can trust the wedge 👇🏻

@ThinkingCC 👍🏻🤜🏻

@FSotoMD A wedge greater than dpap certainly cannot be a chronic condition 😉

“The wedge.” The holy grail of RHC and hemodynamics Hate it or love it, major decisions are made based on it Whether you: • Perform the procedure yourself • Review someone else’s tracings • Review someone else's report   Learn 7 tips to ensure “the wedge” accuracy

@TWilsonMD Full agreement. 👍🏻

@FSotoMD Wedge is typically not greater than PADP. Suggests technical error such as over wedge.

@GamerPhilDoc 100%. Otherwise, you end up making critical decisions based on wrong information due to lack of quality control.

@FSotoMD Couldn’t agree more. Just as we obsess over assay controls in flow cytometry, hemodynamic tracings demand identical rigor. Artifacts mislead across all specialties.

@msiuba 🙏🏻 my friend I miss those days ….😔

Great 🧵 by @FSotoMD from the good old days of this broken app

CADENCE study Very encouraging PVR reduction results (and several other positive signals) Phase 2 trial, Sotatercept in CpcPH (Group 2 PH) Congratulations: @mardigomberg @RyanTedfordMD @jeanlucvachiery @CircAHA ahajournals.org/doi/10.1161/CI…

If you enjoyed the post, please repost the first post in the🧵 #medtwitter #pulmonaryhypertension #sotatercept *No conflicts of interest Other graphs 👇🏻

6/6 Take home: 🔹 No dose response seen (0.3 mg/kg actually had better profile and response) 🔹 Improvement likely mediated by pulmonary vascular remodeling (and not by pulmonary vasodilation) 🔹 Decrease in left-heart pressures (encouraging finding) 🔹 6MWD improvement likely not clinically significant (exploratory outcome, though) 🔹 Concerns about clinical impact of drop in cardiac output (and reason). However, 6MWD increased in 0.3 mg/kg group. Recent study (Reddy et al) found similar CO results.

1/6 Sotatercept in Combined Pre/Post Capillary PH (CpcPH): CADENCE (Gomberg-Circulation 2026) A🧵 (8 min read) But first. 🔹Pulm vasodilators NOT approved for PH with ⬆️ left ♥️ pressures (wedge >15; Group 2 PH). Individualized approach recommended. Humbert (2022) 🔹In group 2 PH (PH LHD), pulmonary vasodilation risks “flooding” the left ♥️ and lungs, d/t ⬆️ wedge and impaired LA relaxation 🔹Studies: no benefit or ⬆️ risks (table 👇🏻)