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

2nd Annual Chicago Hemodynamic Forum @ChiHForum Outstanding hemodynamic meeting 🔹Not only for Cardiologists, but also 🔹Pulmonologists with interest in Cardiopulmonary Physiology and Interaction Learning from the masters: @RyanTedfordMD @JonGrinsteinMD @HFpEF and many more

The only reason a chatbot can provide correct medical advice is because doctors/scientists did original research & wrote it up, and others synthesized that research — informed by & and integrated with their clinical education & experiences — and wrote it down.

Great pulmonary vascular and cardiovascular network meeting this morning at #chest2025 @accpchest Lots of accomplishments and inspiration!

Great insight from @msiuba presentation on invasive CO talk. Regardless of the love/hate relationship with PAC, can’t expect change in outcomes unless there is an intervention. If no intervention, remove PAC. See other pearls 👇🏻 #chest2025 #chestsome @accpchest @CHESTPulmCardio

Colleague: “I wish I’d find a lecture explaining hemodynamics and cardiopulmonary interaction in an easier way…” Me: “Wait, aren’t you going to Chicago’s #CHEST2025? Colleague: “I am, but I don’t want generic concepts. I want to learn how the experts do it.” Me: Say no more! We put together an amazing session just for you! Join us: 👇 🎯 Session Title: "Pulmonary Circulation Advanced Interrogation — How I Do It" 💡 Go beyond routine caths: unmask hidden shunts, interpret difficult wedge pressures, and master fluid/exercise challenges like the experts do. 📅 Tuesday, Oct 21 — 8-9 AM 📍 South Building 503 — Session ID 1067 @accpchest @ChestPulmCardio @ChestCritCare

@hraza222 @khaycock2 @NephroP @msiuba To Dr @msiuba point, lack of RAP (CVP) variation is a poor prognostic marker of RV dysfunction in pre-cap PH, something that your pt is showing…. sciencedirect.com/science/articl…

Why doesn't this VExUS correlate with the PAC? EF <20 in AKI on CKD, recent angiogram, cardiorenal syndrome. VExUS shows at least mod venous congestion. But the PAC didn't correlate. PCWP 10, CVP 11, filling pressures low. CI 2.2 by TD. @khaycock2 @NephroP @msiuba

Comment 2. Meaning, the high PVRI suggests a component of precapillary PH (in addition to LV failure) so that this is not just a plain RV failure that could respond to inotropic agents. Likely needs pulmonary vasodilators (and closely monitoring of wedge pressures), since improvement of R to L flow can worsen left heart filling pressures given such LV systolic dysfunction

Agree that not straightforward Is the patient breathing spontaneously? I’m making that assumption for the comments below. I’m also assuming that every tracing has been zeroed/leveled, etc —- Looks like your RAP (end of exhalation) is around 12ish, which fits your IVC images. Wonder if you are primarily dealing with pressure overload on the right side (plus very low LVEF w/o much pulmonary congestion) The visual TAPSE appears quite abnormal. PAP around 38/28, mean 31 (end exhalation calcs), with PVRI around 9.5 WU/m2. IMHO, pulmonary vasodilation and biventricular cardiac optimization might provide better results by improving forward flow. **CAVEAT I am curious if improving RV performance could worsen left heart filling pressures. Not infrequently, we observe unmasking of diastolic dysfunction in “PAH” pts once you start pulmonary vasodilation, or improve RV function. The left heart pressures might be currently “protected” due to the right heart failure/dysfunction.

@msiuba Congratulations, Matt. Very well deserved! We and your fellows have all benefited from your many generous contributions.

Very thankful to my fellows for the kind recognition. Teaching engaged learners is a privilege.

@msiuba @RyanTedfordMD @AHajduczok @JasonKatzMD @rjbernardoMD @AnnGageMD @CardsNYC @IM_Crit_ @GiessenPh @RRVdpool @chatterJ5 @ThinkingCC Looking forward to reading it!!

A few potentially interested parties: @RyanTedfordMD @AHajduczok @JasonKatzMD @FSotoMD @rjbernardoMD @AnnGageMD @CardsNYC @IM_Crit_ @GiessenPh @RRVdpool @chatterJ5 @ThinkingCC

We present another publication-quality chapter from ShockWaves, the 1st chapter in the RHC section. @CaravitaSergio presents a masterclass on the invasive PA waveform. Section editors: @SophiaAirhartMD & @zilgiovineMD Look out next week for the non-invasive correlates 👀

@redraiderpulmcc @UTK_PCCM Thanks Victor! We are very excited that she matched with us. Your word and feedback reconfirms that! 🙏🏻

@UTK_PCCM @FSotoMD You got a good one in Dr Pandey, @FSotoMD! I’m sure the others are outstanding too but I know from personal experience about Dr P. Congratulations my friend

Outstanding Pulmonary CCM (and Cardiology) Fellowship Match Day at the University of Tennessee Graduate School of Medicine, Knoxville Excited faculty and fellows showed up to support our incoming fellows: • Dr Mohamed Mohamed • Dr Mandvi Pandey • Dr Christy Smith

Let’s discuss “Contemporary Treatment of Pulmonary Arterial Hypertension: A U.S. Perspective” Exciting PC Webinar on 11/25 2 PM EST ⏰ @ATS_PC All star panelists @SandeepSahayMD @IoanaPreston @mardigomberg @JimWhiteCurePAH and MChakinala Register here: bit.ly/4fyIz45

Important point 👍🏻 My opinion (but open to expert disagreement): • With large V waves, “pulling” up the “a” wave, the WP is not truly higher than dPAP, but it’s an“artifactually” higher # • If WP were truly ⬆️ than dPAP, it would cause backward flow • In cases where the WP appears to truly be ⬆️ than dPAP (inaccurate #), confirmation with LVEDP should be considered • Even in very tall V waves, I have “usually” found “a” waveform to correspond to = or < than PADP (see image 👇🏻of ⬆️ “v” wave and good WP (“a” wave/LVEDP correlation). Not sure about the behavior in case of “giant” v waves • I routinely capture the “wedge to PA pullback” for additional reassurance of WP to dPAP relation (shown on 🧵) • Would love to see any examples of much higher WP than dPAP in large v waves (ideally with “pullback screens”) Thanks for the comment!

@FSotoMD It actually might in some instances. Indeed mean WP is measured over the cardiac cycle while dPAP is a punctual value. When big V waves are present (severe MR, diastolic dysfunction, etc) the mean WP may results to be higher than dPAP. Do you agree?

“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

@PacoDardon My 🤜🏻 Yes. For bedside PA caths, I • Advance PAC into introducer to 20 cm PAC line • Then, inflate 🎈full and advance with 🎈inflated (20cm PAC line will be at level of SVC or proximal RA) • Always “sail away” with 🎈inflated • Always “pull back to shore” with 🎈deflated

@FSotoMD Great thread! I'm curious about this in particular, we usually inflate the balloon whilst in the RV in order for the catheter to be advanced in the direction of blood flow. Do you advance your PA catheters completely deflated? And if so, when do you decide to inflate?

If you appreciated this thread, please: PLEASE • “Like” the thread (plus individual tweets if 👍🏻) • Repost the FIRST tweet for others to benefit from this #FOAMed #MedTwitter

SUMMARY 7 tips to improve WP accuracy: 1. WP SHOULD NOT be > than dPAP 2. Distinct “a” and “v” waves 3. Respiratory variability 4. Stationary catheter by fluoro 5. Free flow present 6. Obtain wedge O2 sat 7. Ensure you ONLY inflate the 🎈 UNTIL wedge waveform