Francisco Soto, MD, MS, MBA

Pulm/CritCare | Division Chief | Chair Pulm Vascular Disease Section ACCP/CHEST | Right🫀Cath Connoisseur |🫀🫁 #Hemodynamics | CritCareEcho | My Opinions

[Francisco Soto, MD, MS, MBA @FSotoMD]

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

[Francisco Soto, MD, MS, MBA @FSotoMD]

@MMukherjeeMD @HopkinsMedicine @SteveMathaiMD @LiliBarouch @DrMSWilliams @AllisonGHaysMD @hopkinsheart @HopkinsPCCM @HopkinsMedNews @CiccaroneCenter @JohnsHopkinsDOM @NadiaHanselMD Outstanding Mónica.
So well deserved for your many amazing contributions.
Congratulations!

Francisco

[Naomi Habib @NaomiHabib]

Day TWO of the fun, from your friendly PH social media ambassador!! Here's a sampling of the fun, with perhaps just a tiny bit of cardiac/pulmonary vascular bias 😉

11-12 (North 223): A New Era in PE Management 🫀🫁

11-12 (North 122B): Clots be Gone: A Multidisciplinary Approach to CTEPH Management 🫀🫁

12-15-12:30 (Exhibit Hall): Experience CHEST - PE Care in 2026 🫀🫁

1:30-2:30 (North 227C): Intermediate-Risk PE Showdown: A Battle of Clinical Knowledge 🫀🫁

3:15-4:15 (North 223): PH - Evolving Care and Complex Cases 🫀🫁

4:30-5:30 (North 122B): PH Hemodynamics in the Wild West - Follow the Yellow Snake Trail 🫀🫁

...and yes, if you want to hike in Arizona, you have arrived at the perfect time! 🌵☀️🌵
From the high desert of Sedona to the low
Sonoran desert to the city trails across the Valley, our state is rich in its rugged beauty and history. Check out Piestewa Peak Trail (moderate), Papago Park (easy), and Echo Canyon Trail (hard!), all within 15 minutes of downtown and with beautiful views of the city! Just don't forget to take a lot of WATER and good hiking shoes! 🌵🫁🌵

#CHEST2026
#CHESTSoMe

@accpchest
@CHESTPulmCardio
@SandeepSahayMD
@anjalivaidyaMD
@FSotoMD

[Naomi Habib @NaomiHabib]

The sun rises on the FIRST day of CHEST 2026!!! 🌵🫁🌵 Excited to have everyone at my home city, the beautiful Phoenix, AZ! It’s going to be a great conference! Following along for updates on the conference and behind the scenes looks at PCCM 2026! #CHEST2026 #CHESTSoMe @accpchest @FSotoMD @anjalivaidyaMD @SandeepSahayMD @ATS_PC @PHAssociation @CHESTPulmCardio

[Francisco Soto, MD, MS, MBA @FSotoMD]

ACCP: “Pulmonary HTN runs wild in Phoenix. We are doomed!”

ACCP PVD Section: “Easy, partner. Our 6 top PH Marshals ride Sunday!”

Reminder to come see the PH Marshals in action:

"Guidelines vs Real-Life Expert Decisions in Pulmonary Hypertension Treatment: A Conversation With Experts"

🌵 🌵 🌵 🌵

WHEN: Sunday, October 18, at 1:30 PM
LOCATION:📍 Phoenix Convention Center, North Building, Room 226 A

Arrive early to secure your seat!

🌵 🌵 🌵 🌵

#CHEST2026

Link 👇🏻
https://t.co/Mzm6Y9d35C

@ParthRali
#OksanaShlobin
#JessicaHuston
@melendres_lana
@SandeepSahayMD
@AnnaHemnes
@hilarydubrockMD

@accpchest
@CHESTPulmCardio
@PVRI
@PHAssociation
@ATS_PC

[Francisco Soto, MD, MS, MBA @FSotoMD]

Friend: “For people who fear snakes, why travel to Arizona for #CHEST2026?

Me: “To lose the fear of the yellow snake..”

If snakes make you uncomfortable, especially yellow ones, #CHEST2026 may be your chance to finally “cure” that fear, courtesy of @CHESTPulmCardio and @accpchest

We have put together an outstanding session on pulmonary artery catheterization and pulmonary hypertension:

Pulmonary Hypertension Hemodynamics in the Wild West: Follow the Yellow Snake Trail

🌵🏜️🐍

Join us Monday, October 19, 4:30 PM, at the 📍 Phoenix Convention Center, North Building, Room 122 B

See the attached flyer for details, or follow the link below for the full session information ⬇️

https://t.co/Ht4QoVF2Bt

#EmoryBuck
@MeenakshiSridh4
#AdrianoTonelli

@ATS_PC
@PHAssociation
@PVRI
@ALATorax

[Francisco Soto, MD, MS, MBA @FSotoMD]

Attending #CHEST2026 and interested in cardiac and pulmonary vascular disease?

See the entire list of PVD/CV sessions in one place 👇

Curated guide to pulmonary hypertension, pulmonary embolism, cardiovascular and cardiac ICU content, research activities, and other key CV and PVD-focused sessions.

Many thanks to our stellar PVD Section fellows,
#Romina Gomez and #Laura Saldivar, for compiling this valuable resource on behalf of @accpchest and the @CHESTPulmCardio Network

🌵 🌵 🌵 🌵

#CHEST2026 Phoenix, AZ October 18-21, 2026

@ATS_PC
@PHAssociation
@PVRI
@ALATorax

[Francisco Soto, MD, MS, MBA @FSotoMD]

Friend: "I still struggle managing pulmonary hypertension if the disease doesn't follow the guidelines"

Me: "Aren't you going to CHEST 2026 in Phoenix?"

Friend: "Yes! Why?"

Me: "Say no more!"

The @accpchest and its @CHESTPulmCardio have assembled a session just for you:

"Guidelines vs Real-Life Expert Decisions in Pulmonary Hypertension Treatment: A Conversation With Experts"

🌵🌵🌵🌵

Six legendary PH authorities will ride into town to track down the "WANTED" PH cases that keep us up at night.

Dr. Rali and I will present them with six such case scenarios and will have them answer the tough questions.

Check the attached flier and join us Sunday, October 18, 1:30 PM, at the 📍 Phoenix Convention Center, North Building, Room 226 A

Ride in early and claim your seat. Or you may be left outside eating Arizona dust!

#CHEST2026
#pulmonaryhypertension

@ParthRali
#OksanaShlobin
#JessicaHuston
@melendres_lana
@SandeepSahayMD
@AnnaHemnes
@hilarydubrockMD

@PVRI
@PHAssociation
@ATS_PC

[Francisco Soto, MD, MS, MBA @FSotoMD]

"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 👇
https://t.co/lfjwERf1DH

@atscommunity
@ATS_PC
#ATS2026

[Francisco Soto, MD, MS, MBA @FSotoMD]

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.” 😏

https://t.co/O8CA3bIpSo

🔥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

[Francisco Soto, MD, MS, MBA @FSotoMD]

@redraiderpulmcc 🙏🏻🤗

[Francisco Soto, MD, MS, MBA @FSotoMD]

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

[Juan Pablo Arango-Ibanez @ArangoJuanpablo]

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

[Francisco Soto, MD, MS, MBA @FSotoMD]

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

[Francisco Soto, MD, MS, MBA @FSotoMD]

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 👇🏻

[Francisco Soto, MD, MS, MBA @FSotoMD]

“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

[Francisco Soto, MD, MS, MBA @FSotoMD]

@ThinkingCC 👍🏻🤜🏻

[Francisco Soto, MD, MS, MBA @FSotoMD]

“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

[Francisco Soto, MD, MS, MBA @FSotoMD]

@TWilsonMD Full agreement. 👍🏻

[Francisco Soto, MD, MS, MBA @FSotoMD]

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

[Francisco Soto, MD, MS, MBA @FSotoMD]

@msiuba 🙏🏻 my friend

I miss those days ….😔

[Francisco Soto, MD, MS, MBA @FSotoMD]

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

https://t.co/NJ7KhMksXD

[Francisco Soto, MD, MS, MBA @FSotoMD]

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 👇🏻)