I think it's about time for us to start so I'm going to start. I am Jody Hurwitz. I am president-elect of the Heart Rhythm Society and it gives me incredible great pleasure to welcome you all to the Latin American Summit of 2023, a combination between HRS and LAHRS. This is actually the second year we've been doing this summit. You all be delighted to know that last year we did not have anywhere near the showing that we have today so it's really great that you all can be here in person and that I understand that there's a tremendous number of people on Zoom who have sent in videos to discuss this. This really marks a new chapter I think in global relations between HRS and these organizations, especially how important to us LAHRS is. I think that we look forward to really hearing quite a lot about what's going on all over with all of the different organizations and countries. I think this is incredibly fascinating. I think I'll have everybody here introduce themselves and welcome and we're delighted to have you here in New Orleans. Welcome to HRS 2023. Thank you, Jody. As you heard from our president-elect, I'm Dr. DiBiase and I'm the chair of the Global Relations Committee and it's a pleasure for me to have organized this together with all the involved parties for the Latin America Summit 2023. This is a way to connect Latin America to the HRS. We hope we can be a resource for you at any level that we're going to discuss today from education to economic business and many more. I thank all the partners and all the president of Latin America, HRS, and each other society OVP of Latin America for being here today either in person or as we heard many people are on Zoom. So thank you very much and I give the words to the president of LHRS and to Marcio that actually probably just finished his term. Marcio is the last president. Yes. He's just finished. Okay. Thank you very much for this invitation. We started almost a year ago to prepare this summit and I am very thrilled to be here today with you, my friends, and those who could not attend in person having online. I think it's very important for us to, for our region, to have this kind of meeting, to know the things that we could do better. And I'm sure that HRS will help us, will help our regions. And oh, by the way, Marcio Figueroa from Brazil, LHRS past president. Okay. Good afternoon, everyone. I'm Dr. Luisa Rogel from Mexico. I'm a Latin American Heart Rhythm Society current president. Welcome to this Latin American Summit 2023 organized together with HRS. It's a pleasure to be here with you. In this summit, it's exciting to see electrophysiologists from different countries of Latin America. This summit is part of an initiative to find the EP work community and strengthen the relationship between regional societies. This event will unite EP experts from Latin America to trigger awareness and face challenges in health politics in our region. During two discussion panels and several presentations, you will learn about the most common disease in Latin America, but also you will see the development of cardiac electrophysiologists in different Latin countries, what the current situation is, and limitation and expectation. This summit is a great opportunity to understand our reality, our possibilities, and our limitation would also, it's a great opportunity to identify similarities and differences between us to develop strategies and politics that help us to improve the EP in our region. I want to thank the summit organizer, the HRS authorities, and especially Dr. Nestor Lopez-Camanillas for his enthusiasm in this project. Thank you. Nestor. Just to say thanks to HRS for the opportunity, to the EPs from Latin America that are present or maybe virtual, and for the industry people that are here, and it's a huge, thanks a lot for everybody. And I think it's moment to start, and then maybe I can introduce people. I wanted to say just one thing. I'm sorry for my Sobrek friends, because I don't speak Brazilian, but I speak a little Portuguese, but I speak a little Spanish, if you have a question in Spanish, I can understand it and probably give an answer. Thank you for your presence here. If you want, I can translate from Portuguese to Spanish. Yes, probably. Okay, Nestor, thank you. Well, now we'll start Luiz Aguinaga, he's the president of the Argentine Federation of Cardiology. After him, Dr. Jorge Marim, in representation of the EP Society of Colombia, Dr. Luiz Quineir from Chile. From Brazil, Cristiano Pisani, the scientific director of SOBREK, the Brazilian Society of Arrhythmias. Our last representative, Daniel Banina from Uruguay. Another last representative from Dominican Republic, Fernando Vidal. And from Peru, Richard Soto Becerra. I think it's moment to start with the video. Thanks. I am Dr. Luiz Aguinaga, and on behalf of Argentina Federation of Cardiology, I would like to thank the Organization Committee of Heart Rehabilitation Society for inviting us to present our main clinical problems in our country. We choose as a clinical problem, atrial fibrillation in Argentina, and I would like to present data about our national program, Argentina without atrial fibrillation. The main objectives of our registry was or were fight against atrial fibrillation. Patients focus on detecting new cases, and proper management of sub-treated patients with atrial fibrillation, educational, patient, physician, and community education, and finally investigation to obtain our own data and sub-studies. We address our problem to the community and the physicians. Also we include useful information for patients, information about atrial fibrillation and some maneuvers as know your pores and some treatments as anticoagulation or catheter ablation. And the main resource of our registry were more than 400 of researchers took part in our registry, and all the provinces of Argentina were included, and the program started in June 22. As you know, according to the Global Burden of Disease published in 2014, the prevalence of atrial fibrillation in Argentina was 0.5%, and in our registry the results were we included more than 9,000 patients, and more than 1,400 patients didn't have diagnosis of atrial fibrillation previous to the registry, and more than 8,000 have sub-treated atrial fibrillation, mainly due to anticoagulation. The main risk factors were hypertension, diabetes, hypercholesterolemia, smokers, obesity, heart failure and pulmonary disease. And regarding to anticoagulation, almost 30% of patients, high-risk patients, were off anticoagulation, and 50% of low-risk patients were on anticoagulation, on the contrary, and 12% of high-risk patients were on antithrombosis. And finally, the main socio-economical problems detected were poor patient education, limited access to health systems, unequal access to medicines, mainly anticoagulation, and unequal access to catheter ablation therapy. We think that the first step to solving a problem is to recognize its existence. But we know that in Argentina we have a big problem regarding to atrial fibrillation specifically, and also we need to lead different actions to solve this main pandemic problem. Thank you for your attention. I am a cardiologist-electrophysiologist in Colombia, and we are going to talk a little bit about the epidemiology of heart rhythm diseases in our country. I have no conflict of interest, and I have to emphasize that cardiovascular mortality in our country is a very important cause, the first of all of them. In 2021, almost 52,000 deaths were registered due to cardiovascular disease, the large percentage of them being ischemic heart disease, followed by cardiovascular disease and hypertensive disease. Unfortunately, we do not have a record of our mortality due to arrhythmias. It is estimated that up to 25% of all ambulatory cardiology consultations are related to arrhythmia, and there is a great increase in the incidence of these. By 2016, according to the WHO, 350,000 Colombians suffered from some type of cardiac arrhythmia, and among them, the most frequent is auricular fibrillation, which represents 50% of arrhythmias in Colombia, with an increase in the presentation in it, with a prevalence that for 2003 was 41%, and for 2017 it was 87%, with a great economic burden, being in asymptomatic patients with an annual consumption of 2,500 dollars more or less, and in patients complicated with cardiovascular disease due to auricular fibrillation, up to 24,000 dollars for the annual attention of these patients. The other great pathology that has a great incidence in our population is ventricular tachycardia, within which it should be noted the ischemic ventricular tachycardia, since daily in our country, for the year 2019, 100 patients had a myocardial infarction, and of them up to 20% have ventricular tachycardia, which can become chronic and require intervention from us. And the other cause, which is common in Latin America, is chagas disease, which in our country has a prevalence of 1.6%, equivalent to almost a million patients in our country, and you can see the distribution in the Colombian East of the disease. We also have ventricular tachycardia, which corresponds to approximately 2% of the patients who consult for cardiology, excluding the auricular fibrillation and the auricular ploter. Also, bradycardia occupy a similar percentage of approximately 2%, although we do not have an exact knowledge of the incidence, because we do not have a record of this infection. The strategies involved for the management of these diseases in our country obviously involve the integral management by cardiology of the care of patients with arrhythmias. And in the year 2022, more or less, 8,000 ablation procedures were carried out for curative purposes of the arrhythmias in our patients, and of them, 3,600 procedures correspond to three-dimensional technology. And the distribution by pathologies is 36% of the ablations are auricular fibrillation, 14% ventricular tachycardia, 45% non-complex supraventricular tachycardia and 5% auricular tachycardia. With respect to the management of bradycardia and the implantation of devices, according to the records of the industry that help us in our country, almost 4,000 devices were implanted, and you can see the distribution as the most common is the unicameral macroplasms, followed by the cardiodesfibrillators, both for primary and secondary prevention of the disease. What challenges do we have at this time in electrophysiology in our country? That is to increase the scope of the specialty of the entire population, since it is covered by our basic health plan. We need to increase the use of databases and strengthen these collaborative databases to improve our knowledge of the epidemiology of the disease, educate the population and the medical professionals, and at this time in the country we are carrying out the discussion of a health report that we hope will continue to benefit the population that has arrhythmias in our country. Thank you very much for your attention. Hello, my name is Luis Quineaner, I'm a cardiac electrophysiologist from Temuco, Chile, and in the next five minutes I'm going to try to give you the landscape of electrophysiology in our country. As you probably know, we are this tall and long country, we are about 19 million people living here, and almost 80% use the public system in Chile, which is called FONASA. FONASA has full reimbursement for pacing and ablation, so that means that the patient doesn't have to pay anything to get a procedure done, but the problem is, as many countries in Latin America, there is a really long waiting list, so the patient has to wait almost three or five years even to get an ablation in some areas in the country, and PBI is not an option for many patients in the public health system. The difference is for pacing, because for pacemaker the government has a special program, so you have to wait less to get a pacemaker in Chile. On the other hand, you have the private sector, which is called ISAPRES. ISAPRES has obviously more availability, so there is almost no waiting list, but the problem is reimbursement. These private companies don't give you almost any reimbursement for catheter, equipment, mapping, and eyes, so that means the patient has to pay the full price, and also it means that sometimes you as an EP use less equipment, or less catheters, for example, less HD mapping like PENTERAY or HDGRIP, because it's really expensive and the patient has to pay almost the full price. 5% use other health systems, for example, police and military. In the workforce, we are around 900 cardiologists in Chile. In Chile, to become a cardiologist, you have to do three years of internal medicine and two years of cardiology. We are about 35 electrophysiologists in the country. This is a specialty that is not recognized by the government, so the training is diverse among people. Some people do one-year or two-year fellowship, but most people have a two-year fellowship that can be done in Chile or overseas. We have four institutions that have an EP fellowship here in Chile, Santiago, Concepcion, and Temuco, where I work. But having said that, most people do a fellowship overseas to get really an exposure to complex EP. The public system, we have these numbers. This is the production from last year in all 2022 along the whole country, and as you can see, the most common procedure was pacemaker. We have more than 5,000 pacemakers being done in the public system, around 300 defibrillators and TRTs each, and ablations, they were done almost 700 ablations. But these 700 ablations were concentrated only in three EP centers in Chile, one in Santiago, one in Concepcion, and one in Temuco, where I work. These three hospitals have dedicated an EP lab that we only do EP, and we don't have to share our lab with other specialty like interventionals or vascular. In the private, we don't have strong data, so we don't know how many procedures are done in Chile, but there is some clinics and private hospitals that do plenty of ablation, especially in Santiago, in the capital. We do have numbers from the private companies like Johnson & Johnson and Abbott and Medtronic. And so mapping system, we have Carto and Nsight in Chile. Nsight is quite new. So last year, 2022, we're done only six cases with Nsight. Carto is the most common, so there are the numbers there. 460 cases were done, and from these numbers, 270 AF ablations using RF with Carto. This is public and private. Medtronic is a number provided by them. We did 70 cases of cryo-PBI. So last year, in the whole country, we did 330 AF ablations in Chile in 2022. Scientific societies, we try to be as active as possible. We have, obviously, the Chilean Cardiology Society. We are 900 affiliated cardiologists and other professionals that are dedicated to cardiology, like nursing or physical therapy. We have a small arrhythmia department with 50 affiliated. Thirty-five of them do interventional EP, but we have also really amazing clinicians that do pacemaker follow-ups or genetics or other arrhythmia related to EP. And we try to be as active as possible. So we do monthly Zoom meetings to try to discuss clinical cases or maybe review an interesting journal. And we do an annual meeting that are done in different cities in Chile. This is a beautiful picture you can see here from the meeting last year in Porto Varas, 2022. As you see in the picture, we are already really happy after a full day of discussing EP, clinical cases, and we have some special guests like Karina Hardy here in the middle from Brazil. And the last minute in this talk, we'll be talking about the gaps. So in the public, we need to do more EP. We need more electrophysiologists in Chile. We need more EP labs because most colleagues are really busy doing pacemaker and they don't have time to do an ablation. And in the private sector, we need to improve reimbursement. So these private companies don't give you almost any reimbursement from catheters. So we need to improve that to be able to use a catheter, HD mapping, and eyes. Thank you so much. I'm really looking forward to discussing this with you. Hello, everyone. My name is Cristiano Pizzani. I'm the scientific director of SOBRAC, Brazilian Society of Arrhythmias. And I'm going to bring you here on the Latin America Summit 2023, the clinical issues in Brazil. I'd like to thank Lars and Harvard Society for the invitation. This is our data of our group, but it reflects most of the Brazil. Most of the ablation procedures is SVT ablation. The reason is because this is a public system patient. In the private, we had 50% of the ablations are atrial fibrillation ablations, and 50% are non-atrial fibrillation ablations. But one important point that I want to bring here, that we have a lot of patients with scar-related VT. Almost 20% of our procedures, 15% to 20% of our procedures are scar-related VT. And most of the procedures, 57% of our procedure of scar-related VT procedures are Chagas disease. So Chagas disease is still a big, important issue, clinical issue in Brazil. And why does this occur? Chagas disease is an infectious disease. And we expected during the years that the number of patients with Chagas has decreased. But what we can see here that we have this reduction compared in 1990 to 2019. But still, there are some states in Brazil, especially in the Midwest and Northeast of Brazil, the number of deaths related to Chagas is very high, especially Goiás, Bahia, and Minas Gerais. So Chagas, especially on those states, and our center that is in Sao Paulo area for low risk of Chagas, but we have many referred patients with Chagas, this is a big problem for us. And what's the pathophysiology of Chagas? We have the bug that infects, and this is a chronic disease, and we have fibrosis induced by the bug, but also we have autonomic denervation, and we have some ischemic abnormalities that creates a scar, especially in the infralateral basal area, and especially on the apical idosurface. What we do to treat Chagas? ICD for patients with secondary deprivation and primary deprivation is still not clear in Chagas disease because those patients die suddenly, but many patients die due to heart failure, and this is a progressive disease. This is a chronic infection and progressive disease. So this is a meta-analysis from Andre do Carmo from Minas Gerais when he was in Canada, showing that it's not clear the benefit of the ICD in patients with Chagas. And we have the Chageski study that is in development. Actually, they stopped inclusion of patients. They are now using data, and so we have the clear role of the ICD in Chagas disease, especially for primary prevention. But also a big issue in Chagas disease is the ventricular tachycardia. Ventricular tachycardia is very common in patients with Chagas, and most of the ventricular tachycardia are related to the infralateral basal aneurysm. Chagas have apical and infralateral basal aneurysms, and most of the Chagas disease, they have epicardial VT. That's why epicardial ablation was developed in our center by Dr. Mauricio Scaramarca, Dr. Eduardo Sousa, because they had many patients with Chagas and with failed endocardial ablation. So they had the idea using the anesthesiology needle to reach the epicardial, and many patients could be adequately treated using this approach. But what we can see here is there are many patients, it is a proof of this that we can see, this is my thesis, we have many patients with no endocardial scar, and they have a very large epicardial scar. So epicardial ablation is necessary in patients with Chagas. Our current workflow in INCORP is if the patient has Chagas disease, we go directly to the epicardial, and if you get VT non-induced and elimination of the substrate, sometimes it's not necessary to go to endo. If the patient still has some VT, or there are some areas related to coronary arteries and phrenic nerve, or mitral isthmus VT, then we go endo. But usually in all patients with Chagas, we go epicardial, and if necessary, go endo. This is Cristiano Dietrich recently published data showing that there's a series of 60, 70 patients with Chagas. If you could eliminate all the late potentials, it was a late potential in siloed technique, the follow-up was good. But patients who still have late potentials, who still have substrate, they have a very high recurrence rate of ventricular tachycardia. Some other things we must use for treating Chagas, and we are very happy, and we felt that this could be one solution, is the radiotherapy. Radiotherapy, we can have a transmural lesion. We have now eight patients included. This is the first patient we just published this data. And what we can see that the patients can have VT on the first months, but after this blanking period that could be four months, most of the patients get no more VT. So this could be promising. One issue, one limitation of the radiotherapy could be the stomach and the bowel. But in this series, we have no problem with this. So this could be promising. To conclude, despite improvements in public health, Chagas disease and Chagas disease VT is still a major problem in Brazil, especially in some states in the Midwest and Northeast. Stratification with cardiac MRI is important, but the role of ICD is not completely known, and Chagas study will bring us some more data. Epiglottis is necessary in most of the patients, or I'd say in all patients, and radiotherapy can be a solution, can be a good option for those patients. Thank you for your attention. And now, later we will have a very nice discussion. Thank you. Good afternoon, I'm Daniel Vanina, and I'm going to talk about some epidemiological data on arrhythmias in Uruguay. This story begins in February 1960, when Dr. Orestes Fiandra places one of the first prototypes of the PASO brand designed and made by Rum Elquist at the Karolinska Institute in Sweden. Already in those early days, from the 60s to the 70s, Dr. Fiandra realizes that the main limitation for patients to access and benefit from this technology is the economic one. Therefore, he comes up with something innovative, which is the National Resource Fund. It is a non-state public body that is financed with the contribution, a small contribution from all the workers in the country, plus government contributions, and in this way it covers 100% of the inhabitants of the country of any high-cost technology, regardless of their economic situation. This has allowed the development of electrophysiology. The first thing that was developed, in addition to other cardiological techniques, were the PASO brands. There are 14 implants, 14 implant centers in the country, and there are 9 new centers that make implants of cardiophilic and ablations. As for the PASO brands specifically, these are the statistics of the Fund from 2004 to 2022, where it is clearly seen that there is a gradual increase, accompanying the global trends, the decline of the pandemic and how we recover the pre-pandemic levels. And specifically, in blue we have the PASO brands requested by the doctors, in green the authorized ones, and in red the ones denied by the Fund, which are less than 1%. This is a correct situation, this is how the whole system should work, where basically a person who is seen by a doctor and needs a PASO brand, is given the PASO brand without problems. If we make the comparison with the implants per million inhabitants, if we compare with other countries, we choose the European Union because we have many similarities that we will discuss later, but basically Uruguay has 400 implants per million inhabitants, when we should have a much closer figure to Europe of 1,000 implants per million inhabitants. Why did we choose Europe? Well, the evolution of the population pyramid in Uruguay has made us have, in the 1960s, a young pyramid with a very broad base, young people, an old pyramid, an inverted pyramid, decrease in birth and immigration, which make Uruguay have a population, here we see the Uruguayan pyramid compared to the European one, they are very similar. So, the limitations of Uruguay is that we do not have enough PASO brands per inhabitant, there is no discrimination in the data provided by the National Resource Fund, neither in the diagnosis nor in the type of device, and we have technological limitations, there have been great technological advances in recent years, but the National Resource Fund has not incorporated the PASO brands without cables, it has not incorporated the remote monitoring, which is only available in a center, it has not incorporated all resynchronization materials, we are limited, for example, we do not have access to cell wallets through the Fund, and we have limited indications of the stimulation of the left branch. As for the defibrillators, the situation is much darker, implants have been increasing over time, in blue we have the implants requested by the doctors, in green the authorized, in red the denied, the Fund denies 43% of the requests, why does it deny it? Because the Fund has its own regulations that are separate from international scientific evidence and are globally accepted, for example, in primary prevention in ischemic cardiopathy, the Fund requires that patients have FEV-35 but greater than 20, all patients with FEV-20 are excluded, and they must also have one or two of these risk factors, if they do not have any of these risk factors, they are also excluded, and if they have three or four, they are also excluded, and as you can see, as here is class 2 of the ring, if they have class 1, class 3 or class 4, they are excluded. In ischemic dilated cardiopathy, the situation is worse, because it does not cover any type of indication, never in its entire history, the Fund has covered any implant in ischemic dilated cardiopathy. And if we compare the implants per million inhabitants, we see that Uruguay has 60 implants per million inhabitants, compared to Europe, which has 174, that we should be much closer to those figures to make justice to reality. As for studies and talks, the history of studies and talks begins in the 80s, when Dr. Palmira Banzini, who was the mother of electrophysiology in Uruguay, begins the first studies in 1981, and then graduates abroad in San Pablo. Dr. Simon Milstein, in 1983, goes to Canada and graduates with George Klein, and then settles in Minnesota, and many electrophysiologists went to graduate there, and returned to work in Uruguay, so it is up to us to designate them, the mother and the father of invasive electrophysiology in Uruguay. Unfortunately, in Uruguay we also have regulatory and important problems in this regard. In 2008, the government established an integral health assistance plan, and there it is established that it is what the providers should give to the patients, but the studies and talks were intentionally excluded. The excuse is always the economic one, it is very expensive, but it should be remembered that the Fund spent, in the latest available data, in steps, it spent 4.5 million dollars, in cardiofibrillators, 2.3 million, and in other techniques that it has been incorporating recently, ranging from oncological drugs, assisted reproduction, mechanical stroke treatment, TAVI, or all endoprothesis and peripheral interventions, only in oncological drugs, it spent 35 million dollars in a year. Despite these regulatory limitations, which have not allowed the development of studies and talks, there are four teams working in new hospitals, conventional talks are made, about 500 per year, the most common diagnosis is anodal re-entry, the accessories to the flutter, with successes of 98, 99, 95%, similar to Europe and the United States, which speaks of a highly trained medical population, and with the three-dimensional mapping system, very few cases are made, we have an estimated success of 45% in the first procedure, with the recurrence of auricular fibrillation of 25% in 6 months. The big problem in Uruguay, apart from the regulatory, are the very heavy tax systems, which makes the supplies count almost 4 or 5 times, what they cost in the United States, and also determines that the equipment is old, we still have some first-generation test running, we have a couple of second-generation tests, we do not have the most modern systems, we do not have high-density mapping catheters, we do not have contact force, we practically do not have CRIO, which has just arrived in March, but no patient has been made, and we practically do not have ECHO, which although there is, the cost is prohibitive to use it in all patients. So, in a FODA analysis, Uruguay has as strengths, a universal coverage system, and highly trained staff, with comparable results to developed countries. In terms of weaknesses, we have a very hard tax system, very heavy, which limits access to technology, and that we have old technology. The opportunities are that the expansion of electrophysiology in neighboring countries, will help us, and is promoting the development of electrophysiology in Uruguay, and our great threat are, the bad sanitary regulations that we have. And as in the end, everything ends well, if it does not end well, it is not the end, we are convinced that the best, for electrophysiology in Uruguay is yet to come, and we thank you very much for listening to us. See you later. Hello, it's a big honor for me to be here, to share with you our Dominican Republic, clinical experience in the arrhythmia field. I will continue my presentation in Spanish. About 77, for men almost 72 years old. The biggest cause of death is cardiovascular disease, representing 70% of deaths in 2022, according to the National Office of Statistics. As for our risk factors, according to the study published in the ICC 2018, the Dominican population, 31% have blood hypertension, with slight prevalence in women, obesity 60%, sedentary lifestyle also 60%, diabetes mellitus 5.6%, premature cardiovascular disease 33%, and tobacco use only 12%. As for auricular fibrillation, which is our main arrhythmia problem, the Dominican Institute of Cardiology, in a sample of a little more than 800 patients, accompanied for a year, who had devices, found in electrocardiograms, at least 3 per year, an incidence of 6.2%. And it is estimated that the general incidence of the population above 65 years of auricular fibrillation is between 8 and 9%, representing approximately 50,000 patients. Stroke is a very important problem in our region, and in our country in particular too, with a figure that exceeds 170 cases per year, and represents, in this way, the main cause of death in the entire Latin American region and in our country as well. Even so, social security does not cover direct anticoagulants for patients, it has a coverage of approximately 200 dollars per year in medicines, and a direct anticoagulant, for a month, costs 120 dollars. In relation to the statistics or informal data that we have, made according to a questionnaire, our main arrhythmia problem is auricular fibrillation, bradycardia and blockages are very common too. Although ventricular tachycardia, or ventricular arrhythmias in ischemic cardiopathy, is very frequent, there is very little reference, therefore, very few speeches, even when ischemic cardiopathy is the main clinical problem in our country. This represents a high incidence of sudden death and also of ischemic cardiopathy failure, being this greater than 50% in the data presented in Circulation in 2020. The second cardiopathy etiology is valvular, then followed by congenital pathologies. We have 15 electrophysiologists specialists, divided into 12 electrophysiology laboratories. Four of these laboratories have three-dimensional masps approved by FDA. A cryovabilation system that presents many problems with the importation of nitrous oxide, which makes productivity difficult. Approximately 1,500 devices are implanted in the country, these being very few defibrillators, very few high power. Approximately 600 speeches are made, of which 150 to 200 are auricular fibrillations. To graph what happened after the beginning of social security, we have this design, which is the statistics of the Dominican Institute of Cardiology. Since 2007, when social security coverage began, devices were fired, but even today there is no coverage for high power devices. What are our main challenges in the future? Above all, to promote communication at all levels, between specialists, between specialists and institutions, institutions and public administration. To generate our own statistics. To educate not only the population, but also our colleagues, internal cardiologists, general doctors. After this, and this communication, to generate policies, not only of prevention, in terms of generating greater device coverage, but also of medicines. Thank you very much. It is a pleasure to be able to address all of you and to be at the HRS LARCH Summit 2023. My name is Richard Soto de Serra. I am a cardiologist and electrophysiologist at the Instituto Nacional Cardiovascular INCOR. Today we will talk about the current state of the disorders of the heart rate in Peru. We do not have national records that describe the epidemiology of heart arrhythmias. However, our experience in conventional ablation began in 1998 with Dr. Ricardo Segarra, who was the first electrophysiologist in Peru to carry out this type of procedure. And from 2017, our experience in 3D ablation began at INCOR with the CARTO3 technology, which allowed us to develop a very interesting experience and case study, which has allowed us to develop records and studies that evaluate the effectiveness, security and impact of 3D ablation on the quality of life of patients. We do not have epidemiological records, but we do have data that records the income of catheters and devices in 2022 in our country. Regarding heart stimulation devices, bicameral heartbeats are the most frequent, a total of 1,782, followed by the unicameral strokes, a total of 907. The devices for the prevention of sudden cardiac death, such as the unicameral defibrillators, reached a total of 92, followed by the bicameral strokes, a total of 122. The number of marcapasos implanted per million inhabitants in Peru reached 84. If we compare it with Europe, the number of marcapasos implanted per million inhabitants is 938. A fairly significant difference between both populations. Regarding the speech catheters, the conventional catheters were the most frequent, 587, and also the 3D speech catheters, 292. This is interesting because it has been increasing progressively. At the National Institute of Cardiovascular Sciences, we have data that allows us to identify the diagnoses of marcapasos implants. We have identified in 2022 that block B was the most frequent diagnosis of the marcapasos implant, 70%, followed by the Sennheim-Fermo syndrome, 30%. Regarding the DICE implant, the diagnosis or reason was primary prevention, the most frequent, 80%, followed by secondary prevention, 20%. The most frequent diagnosis was hypertrophic myocardiopathy, 52%, followed by ischemic cardiopathy, 17%, and the other cardiovascular. Regarding conventional speech, the most frequent diagnosis was tachycardia by input B, 84%, followed by intranodal tachycardia, 16%. Regarding 3D speech, in 2022, ear fibrillation was the most frequent diagnosis, reaching 34%. And we have the first 3D speech record in Peru, which was published in 2021. We included 126 patients, and the most frequent diagnosis was 19% ear fibrillation, followed by ear tachycardia and ear stress. The acute success reached was 95.9%, and the free survival of recurrences was 74% per year. Complications reached 4.8% and we had no problems. A study has also been published that evaluates the impact of 3D speech on quality of life in patients with idiopathic ventricular arrhythmias at the National Institute of Cardiopulmonary Research. For this, we carried out an analytical study that compared the quality of life in these two groups of patients, 3D speech and antiarrhythmic speech. We used the SF36 questionnaire, and the total score achieved in the 3D group was 85.1% versus 68.4% in the antiarrhythmic group. There was a significant weight. We concluded that there is a low coverage of attention to patients with cardiac arrhythmias, and this is because we have a reduced number of electrophysiologists, a reduced number of specialized centers in the management of cardiac arrhythmias, and a poor funding in some groups of patients. It has been shown that there is a very low number of devices implanted per million inhabitants in our country. And our records show that 3D speech is an effective and safe method for the treatment of complex arrhythmias in Peru. The new technologies have undoubtedly helped improve the effectiveness and safety of this procedure. And in turn, it has been shown that there is an improvement in the quality of life of patients who go to 3D speech, especially those who have arrhythmias. Thank you very much for your attention, and we will see you again very soon. Thank you very much. I want to introduce the following presenters. From Ecuador, we will start Jorge Arbaiza. He will represent the Ecuadorian Society of Cardiology. After him, Federico Malavasi is our last representative from Costa Rica. From Bolivia will be Roberto Torres Molina. That is also a last representative. After him will be Dr. Shamya Venchetrit from Venezuela, in representation of the Arrhythmia Committee of the Venezuelan Society of Cardiology. From Salvador will be Marta Reyes, that is our last representative. And finally, from Cuba, Elibet Chavez. Please start with the presentations. First of all, we would like to thank you for the opportunity to participate in this Latin American Summit of 2023. I am Dr. Jorge Luis Arbaiza Simon. I am a cardiologist and electrophysiologist from the city of Quito, Ecuador. We will talk about the data of electrophysiology in our country. First of all, we are talking about a country in which the life expectancy has increased significantly in the last 50 years. We are talking about a life expectancy of 73.7 years, and that means that the older population faces more arrhythmias, mainly what is auricular fibrillation. This is a short summary of how the health system in Ecuador is organized. The health system in Ecuador, as we see, we have a total of 630 health establishments, of which there are more of the private service than the public service, and we have a total of care, in this case of hospital beds, of around one million patients per year. As we can see, despite the fact that there are more private companies than public, the number of beds is higher. When we wanted to see, with respect to the incidence and prevalence of heart disease, we are facing this situation. We analyzed the first 10 causes of death, as we can see in this graph, and while it is true, both in our country and in others, COVID has represented the main cause of death in 2020-2021, heart disease is in the second cause, but specifically ischemic disease. And if we are going to look for causes of death of heart arrhythmias, we do not find them among the first 10 causes of death. So, specifically, what can we say about Ecuador? A national statistic of incidence and prevalence of heart disease does not exist, unfortunately. A record is being made through the Ecuadorian Society of Cardiology, specifically in the city of Quito we are doing it, with 8 hospitals, both public and private, the largest in the city. And I can give you specifically the hospital in which I work, in which, for example, in the year 2022, we have 235 cases of ear fibrillation, which would represent 3.2% of all diagnoses carried out in hospitalized patients. This, of course, is not a number that is representing prevalence or incidence of the disease, but we can have a certain approximation in this regard. What are the requirements in our country to be able to exercise as an electrophysiologist, to have a recognized title as a cardiologist with a specialization in electrophysiology? There is a national entity known as CENESIDA, currently known as ACCESS because they changed the name, which is in charge of recognizing these titles. How many do we have in the country? We have 33 electrophysiologists who are distributed in the main cities, most of all in Quito, Guayaquil. We have Cuenca, Manta and Loja. These are the five cities in which we have specialists in their specialty. Unfortunately, there is no fellow here in the country. All electrophysiologists in the country are trained in other countries. And we can get a statistic, if in the country there are 17.8 million inhabitants, we can say that there is an electrophysiologist for every 540,000 inhabitants. Regarding a gremial association, since 2020, and precisely because of the pandemic, we began to have meetings within the cardiology society to try to organize what are the committees, and specifically the electrophysiology committee was organized with the interesting issue that it had specialists from all the cities that we had mentioned, and since then we have been able to organize several national events and three international days, both with the approval of the CIAC and the Latin American Society of RIT. There is no relationship with government entities, and in that sense we do not have the support of the government. As for centers and technology available, we have 15 centers in the cities already mentioned. Conventional and three-dimensional mapping systems have been used for some years now. Both radiofrequency energy and cryoablation are used. As novel issues, cardioneuroablation is done in some centers. Intracardiac echo is used as a method to collaborate in the improvement of procedures. And as for devices, we can say that all types of devices are implanted. Step-by-step with conventional stimulation, with physiological stimulation, cardiodefibrillators, resynchronizers, event recorders. That is, we can say that in the country all kinds of procedures are done. With respect to medical coverage, unfortunately in the public part there are only two hospitals at the state level and three hospitals at the level of social security to practice electrophysiology, but unfortunately, especially in recent years, we have a lot of problems with the materials. As for private clinics making agreements with social or state security, currently, unfortunately, it is almost zero, especially due to lack of payments. And regarding private clinics, there are many private insurances, but unfortunately many of them do not provide what is material coverage. And we know that materials are the most important thing in the expenses of an electrophysiology procedure. And also in Ecuador, we still have many patients who would be considered self-financed in private clinics. Unfortunately, and that is why I underline it in big letters, the high cost of materials with respect to countries in the region, and unfortunately, it is mostly due to the lack of direct representatives of the companies, has brought us that the costs are very high in the procedures, especially in the three-dimensional mapping, and the high taxes there are for the importation of equipment also bring us great difficulties. Regarding technology, we have the large companies, with more than 20 years in the country, through the national company called CGMED, with them we can count on all the systems that we are mentioning here, also Medtronic, approximately 20 years, through Ecuador, we have the company Boston, through a national company called Equasurgical, and the last one that has entered is BioSense Western, that is, Johnson & Johnson, through a national company called Primus Medical, that has brought the CARTO system. There are small regional representations of what is BioTronic and Medico SPA. If we talk about national health policies from the State, as we said at the beginning, there is no specific plan by the Ecuadorian Ministry of Public Health regarding the specific and general management of the arrivals, and it is being planned through the Electrophysiology Committee, perhaps in the not-too-distant future, of the Ecuadorian Society of Electrophysiology as an independent entity. Finally, we want to mention some isolated statistics of high-volume centers. In this case, thanks to the help of Dr. José Llorente, we can count on the statistics of two large clinics in Guayaquil, in this case La Clínica Alcibar, that we can see a total between 2020 and 2023 of 786 patients, as we see a higher load of patients in what is conventional ablation of paroxysmal tachycardia, in second place, auricular fibrillation and auricular arrhythmias in general, then the use of step-marker for arrhythmias, the ablation of ventricular arrhythmias, and finally, ear closure. Another hospital in Guayaquil, 480 patients from 2018 to 2023, paroxysmal tachycardia is still predominant, and regarding a center in Quito, in which I work, the Hospital José Andrés de Quito, from 2020 to 2023, 499 patients, of which paroxysmal tachycardia is still predominant, in second place, fibrillation and flutter, in third place, ventricular arrhythmias, especially ventricular trachystolea, and we also have stimulation of both normal step-marker and cardiodesfibrillators or resynchronizers. This is all we had regarding Ecuador, we thank again the opportunity of being able to participate in this event of the World Rhythm Society, and we want to say goodbye on behalf of this country, as mega diverse as Ecuador, with its four regions. Thank you very much. Greetings, I am Federico Malabasi, cardiologist and electrophysiologist from Costa Rica, I will present the data on the state of electrophysiology in our country. Let's start with the incidence of the most frequent arrhythmia in our country, which is atrial fibrillation. The population of Costa Rica is 5.2 million, according to the data of the national census carried out in 2022. The incidence of atrial fibrillation is variable according to age groups. Before the age of 55, the cases are isolated. It does not even reach a report of 1 in every 1,000 inhabitants. From 55 to 64 years, the incidence is 5 in every 1,000 patients. From 64 to 84, the incidence doubles to 10 in every 1,000 and more than 85 years or more, we already have an incidence of 35 cases per 1,000 inhabitants. As for the second most frequent pathology, regarding electrophysiology, we have supraventricular arrhythmias, which include re-entrances and flutters. We have an incidence in two age groups reported according to the census, which is 20 to 55 years, 7 in every 1,000 inhabitants, and above 55, 8 in every 1,000 inhabitants. In 2022, we have a record of 30 episodes in the National Statistics of Patients with Ventricular Fibrillation and 100 episodes of ventricular tachycardia. It is important to be clear that there may be and evidently there is a sub-registration in terms of ventricular arrhythmias, because many patients have presented as the first sudden death presentation and it is not classified as such within ventricular arrhythmias. Subsequently, we have a diagnosis of attention for bradycardia. There are 1,000 cases per year in the National Census statistics. If we look at the production of electrophysiology procedures as a second section, we have a report of 150 national reports of atrial fibrillation, 300 cases of ventricular arrhythmias, 50 cases of ventricular arrhythmias. This includes both ventricular arrhythmias and ventricular extrasystole. We have implants of 800 devices of the Markapassu type, either unicameral or bicameral, at the national level. We have 60 implants of unicameral and bicameral defibrillators. And finally, a national total of 100 implants of cardioresynchronizers. As a second topic of this presentation, I am going to clarify a little about medical care policies at the national level. The country has 9 electrophysiologists. Of these, 1 is a pediatric electrophysiologist and is the only one at the national level. We have 8 electrophysiologists, of which 5 work at the level of social security, 3 do not exercise as such as electrophysiology, 1 only works in private medicine. From the previous group, it is also important to clarify that only 4 of them perform three-dimensional intervention and speech procedures as such, the others are more dedicated to the diagnostic and implantology part of devices. The requirements for the exercise of electrophysiology at the level of Costa Rica include the incorporation to the professional school, which is the Medical and Surgeon College of Costa Rica. This has some elements that must be completed, whether it is electrophysiology, especially in Costa Rica, require study abroad. There are no academic training programs in electrophysiology at the level of Costa Rica. All electrophysiologists have studied abroad. So, it requires that cardiology is incorporated. This requires cardiology, internal medicine, and later electrophysiology, which requires a year of social service, where the Ministry of Health requests it, and also to approve the incorporation exam carried out by 3 academic partners, national or international, which the college names. We have an infrastructure at the level of social security, public hospitals, 4 hospitals, 1 for children and 3 national hospitals for adults. In 2 of them, electrophysiology is carried out. The center of greater volume and the one that carries out greater complexity at this time is the Calderón Guardia Hospital, where three-dimensional speech is done, high and low-energy devices are implanted for electrophysiology. The Mexico Hospital only performs low-energy device implants. The San Juan de Dios Hospital performs conventional speech. At this time, it is not performing three-dimensional speech. High and low-energy devices. And within electrophysiology, it is the only one that includes earplugs. The other hospitals have the earplug program within modinami and structural, not within electrophysiology. The Children's Hospital does all kinds of implantology and high- and low-energy devices. Public hospitals have all the equipment. There is three-dimensional, polygraphs, creolation, angiographs. The San Juan de Dios Hospital is not performing cryo at this time, and the Children's Hospital does have absolutely all the equipment. There are 4 private hospitals. The 4 of them perform all kinds of procedures and have the necessary equipment. So, the technology is available both at the public and private level. Financing of the cases at the social security level is the social security. The electrophysiologists are by salary and by time, they are not by case, so it is a fixed salary, regardless of the production they have. At the private level, it is paid as follows. 70% of the volume comes through polyses and medical expenses reimbursement. Most of them are international. 30% are national polyses. And direct patient payment, 30% of the volume. There is financing by private banks and commercial houses, according to agreements with third parties. Reimbursement. In fact, 20% of the cases, the patient pays and he takes care of his own reimbursement with his company. 80% of the time, it is necessary to authorize the case so that it is feasible to carry it out. Average waiting time for reimbursement, both for the doctor and the patient, is between 60 and 70 days. Origin of the patients, 60 national, 40% are foreigners. The largest volume of foreigners comes from North America, that includes the United States and Canada. 8% are Europeans, 2% Central America and the Caribbean, and references. Thank you very much for your participation. Any questions, we are at your service. Thank you. Good afternoon. I am Dr. Roberto Torres Molina, member of the Artificial Stimulation and Arrhythmias Committee, the founder of the Latin American Society of Cardiac Arrhythmias and the Bolivian Society of Cardiologists. Bolivia is a country located in the heart of South America. It has about 12 million inhabitants, according to the latest census project carried out in 2012. In recent decades, there has been an urbanization of the rural area. Currently, 62% of the population lives in the cities. 30 years ago, it was quite the opposite. This is the population pyramid of Bolivia, where you can see that there is an equality almost between men and women, but the most striking thing is that 50% of the population of Bolivia is less than 20 years old. This is the basis of the population pyramid. In our country, there are different health and insurance entities. First, there is the Ministry of Health, which corresponds to the Ministry, the governments and the municipalities. The authentic health insurances that are selected according to a well-defined population, such as the national cash register, the petroleum cash register, roads, banks, universities, etc. Then there are the private health insurances that are prepared, the public hospitals that treat patients in a second and third level, the health centers that are in the first level, the private hospitals clinics, and finally the health posts. According to this segmentation, look, for the Bolivian population, 20% attend these authentic health insurances, 9.7% in private areas, 61% in public health establishments, 16% in private health establishments, 17% go to a traditional doctor, 40%, that is, almost half, look for home solutions, and 46% ask the pharmacist what he can take for his validity. In Bolivia, the disease with the highest incidence is HIV, with an incidence of 8 to 12% in urban areas and almost 30% in suburban areas of zero positive patients. Of this disease, the main disorders are manifested, myocardial inflammation with deterioration of the ventricular systolic function, disease of the sinus node, conduction disorders, ventricular blockages, ear fibrillation, ear alopecia and ventricular arrhythmias. This is more or less the distribution and risk inclusion of how Chagas is distributed in Bolivia, with the red dot being the one with the highest incidence and the one with the lowest. There is a low incidence of other types of arrhythmias, such as supraventricular tachycardia, ear fibrillation, ear alopecia, tachycardia of the ventricular aorta, pulmonary aorta, World Parkinson's Disease, ventricular exorcism and ventricular therapy. The implantation of Marcapax was initially published by his cardiovascular surgeons. It is from the year 2000 that, with pioneers such as Dr. Ronald Cuellar and Luis Rangel, the age of electrophysiology of the implantation of cardiac devices by electrophysiologists begins, work to which other professionals will be added, all trained abroad. It is in 2019, on the occasion of having organized the first training of electrophysiology and arrhythmias, that the Arrhythmias and Electrophysiology Committee of Bolivia is constituted. In the photo, the founders. To date, there are seven electrophysiology laboratories in the private sphere, distributed in three of the main cities of Bolivia. Three authentic insurance hospitals, a single first-generation website browser, all other centers work with 32 or 64-channel polygraphs. There is no infracardiotic echography availability. There are no training programs of fellows in electrophysiology, and there is only one center that has reported the areas of ear fibrillation. Four examples. The implantation of cardiac devices is segmented as follows. In the private sphere, with total self-financing of the patient. In private insurances that recognize the implant and not the device. In authentic entities, some give the device and the surgery, and others under revolution. And finally, public hospitals, if they have the means, check the surgery, but do not give the device. Some statistics. In the last year, in 2022, a total of 428 procedures have been done, of which almost half of them were physiological procedures, and not as tactical, for example, intranasal or auditory. 54 auditory allergies, 4 auditory fibrillations, 46 auditory fibrillations and 45 ventricular fibrillations. And the device implantation, 771 devices, of which 154 are single-chamber, 606 double-chamber, 12 bipolar resynchronization therapies, 1 quadripolar, and 8 implant cardiologists. Thank you very much. Greetings. I will comment on the current state of clinical electrophysiology in Venezuela. Unfortunately, there is no reliable data on the number of cases, both of stimulation and invasive electrophysiology. The volume of implants in recent times has increased gradually. The recovery of electrophysiology has been very slow. There has been a significant emigration of electrophysiologists with serious training. In general, invasive electrophysiology is concentrated in some capitals of states with a larger population. A hospital center trains electrophysiologists consecutively, and a second hospital trains cardiologists in cardiac stimulation. At the moment, they do not have any kind of university approval. In Venezuela, the health of 90% of the population depends on the state, and only 10% has private insurance with different levels of coverage. Few public centers implant devices. Some centers have a direct contribution from patients or institutions, which are known as semi-public. You can see that the third most important state in Venezuela does not have a public center for device implantation. Devices are acquired by the state, as well as by the patients themselves, for direct purchase. The largest hospital in the capital, the University Hospital of Caracas, implanted more than 500 devices last year, mostly anti-radical. As for the private sector, the percentage of national level implants depends on the availability of state and private centers. In some states, as I mentioned in the previous slide, private activity represents 100% in general with low volume. There is no regulation that controls who implants the devices, as well as the centers suitable for such. Many private centers in the country implant, several of them less than 10 devices a year. Electrophysiological activity is even more complex. It is still scarce, despite a slight increase in recent years. Probably no more than two 100% state hospitals have the possibility of carrying out invasive electrophysiology. Probably less than 20 cases a year. Some semi-public centers carry out these procedures. You can see in the right slide that practically no state of the most important has the possibility of carrying out implants. In the state of Lara, the semi-public centers carry out more than 50 implants per year with conventional technology. It is an undefined number in private institutions. Activity in private institutions generally tends to depend on mobile devices belonging to certain companies. In the metropolitan area of Caracas, where there are more than 5 million inhabitants, more than 70 cases are carried out per year. This is a 50-40% increase using navigation. in this case, Ricardo B7 Prime. The Chagas problem is still present in Venezuela, with a rebound in recent years. Six million people live at risk of contracting Chagas disease, especially in rural and semi-rural areas. There are probably more than 300,000 cases of Chagas disease in Venezuela. Recent estimates show that the zero prevalence of trypanosoma cruzi exceeds 10% throughout the country. Higher values in the critical transmission points are active in the states of Varinas, Lara, Portuguesa and Trujillo, which is known as the Andean Piedmont. In general, the population is in more complex socioeconomic situations. In recent years, Chagas has been described by oral transmission, as well as cases transmitted by vectors in large urban areas, such as in the metropolitan region of Caracas. In general, few Chagas patients have high-voltage therapies. Thank you very much. Hello, I am Marta Reyes, an electrophysiologist from El Salvador. Thank you for inviting me to this Latin American symposium. I am going to talk about some clinical aspects in the area of electrophysiology in the country. The total population in El Salvador is 6,187,000 people. Within the clinical problems in the area of arrhythmias in the country in order of frequency, we have auricular fibrillation with a prevalence of 15%, and within this, secondary lethiology is the most frequent. Other supraventricular tachycardias, such as re-entry in the tranodal, accessory pathways, flotter atrial, follow them frequently. Later, ventricular arrhythmias related to ischemia, complete ventricular blockages of degenerative theology, bradycardias. Within dysautonomia and neurocardiogenic syncope, this has been increased in this post-COVID stage. Ventricular arrhythmias associated with cardiomyopathies, including Chagas disease, which in our country has a prevalence of 3.3%, and in a smaller percentage we have ventricular arrhythmias associated with hereditary conditions, such as Coutel-Largo syndrome and Brugade syndrome. Within the treatment, we carry out speech procedures when this is possible, either by the ability to speak or by the availability of the procedures, the devices when it is possible and in the same way, and within the treatment options available in the country, we have within the 1B group, Lidocaine, Fenitoin. Within the 1C group, we have Propafenone. Within the group of beta-blockers, we have greater availability, including Metoprolol, Arbedilol, Propranolol, Nebibolol and Visoprolol. Within the group 3, we have Miodarone. Within the group of calcium blockers, we have Verapamil and Diltiazene. and other drugs such as atropine, divoxine and ibuprofen. Among the electrophysiological procedures carried out, we have the electrophysiological diagnostic studies, the talk of supraventricular tachycardia, excluding auricular fibrillation and some ventricular arrhythmias, the device implantation, which is the largest percentage in step markers, and to a lesser extent, defibrillators and cardiac resynchronizers. What are the main problems we face to give adequate management or appropriate treatment to arrhythmias? Mainly, the ability to pay for our population, the lack of technology or equipment, and the facilities for the implementation of these, and to a lesser extent, the access to devices and some drugs that we often do not have with most of them to give adequate management. Thank you. First of all, I would like to thank the Latin American Summit of the Society of Cardiac Rhythm 2023 for the integration that is intended. I am Dr. Eliber Chavez González, Head of the Electrophysiology Session of the National Group and the Society of Cardiology of Cuba. Initially, we will present the topic that has been requested, which is related to the clinical presentation of arrhythmias in our country. When an arrhythmia is documented in an electrocardiogram, patients will always be referred to a cardiologist, which exists in any province of our country, and they will receive a pharmacological treatment according to the current guidelines. When they do not resolve with the pharmacological treatment, they are sent to specialized electrophysiology centers with the aim of making a payment, or of imposing a pharmacological treatment as a strategy for the experience of these centers, which may be superior to the rest of the centers in the country. In terms of epidemiology and the importance of the strategic management of arrhythmias in our country, in the case of supraventricular arrhythmias, we can say that the epidemiological behavior in terms of incidence and prevalence is similar to what is described in international literature. Here are the supraventricular arrhythmias that are presented, and here are the forms of treatment that can be applied in each of them in our electrophysiology centers or cardiology centers in Cuba. In the case of ventricular arrhythmias, it is worth mentioning that epidemiology is similar to what is described in literature, and thus the treatment that is applied is related to what is described in the current treatment guides for cardiac arrhythmias. In our country, approximately 1,100 to 1,200 electrophysiological studies are carried out, and about 750 to 800 talks are carried out in the two electrophysiology centers that we have already described that exist and that we are going to show you in another presentation. From the point of view of cardiac devices, it is worth mentioning that the greatest number of step marks are implanted in patients due to degenerative ventricular blockage because the fourth part of the Cuban population exceeds the age of 65 years. Infectious diseases such as chaga are very rare and congenital ventricular blockages can appear with the need for a step mark implant. Devices such as defibrillators and cardioresynchronizers are also implanted. There are 15 step mark implantation centers or there were 15 step mark implantation centers before the pandemic in 2018, and observe that on average, the centers that are most implanted are the Institute of Cardiology and Cardiovascular Surgery of Havana and the Ernesto Che Guevara Cardiac Center of Santa Clara. When we are going to check the implantation of desinfibrillators and resynchronizers, observe that the desinfibrillators are implanted at approximately 178 and the cardioresynchronizers are implanted at approximately 190, with a rate of 10.7 devices per million inhabitants, which is not similar to the European and developed countries' records, but we can mention that this rate is very similar to what happens in the countries of our area of Latin America. Desinfibrillators are implanted more frequently in patients with ischemic cardiopathy and 28% in patients with non-ischemic dilated cardiopathy and 10% in heart disease. Almost all devices are implanted in patients with a 35% reduction in ejection fraction and that have already presented a sudden death. Therefore, secondary prevention is the first form of implantation of cardiodefibrillators in our country. Here I show you a photo session from our capital, Havana, where the Institute of Cardiology is located, and from Villa Clara, where the Ernesto Guevara Cardiocenter is located. Thank you very much. Thank you very much. So we can start the discussion now. Actually, you know, I've been following the presentation very well and, you know, I will start the conversation with two major issues that I focus on. So I say that child disease is present in many, many countries and is probably a major problem. And number two, the availability of EP labs and the availability of catheters and I would say also availability of doctors. In many countries, I saw 35 to 40 EP without even proper training to get there. So I would like to start a discussion saying what do you think can we do or, you know, how can HRS support number one, training, and number one, more training of people, and number two, probably availability of, you know, catheters and things like that. Probably, you know, PFA, for example, is supposed to reduce the learning curve and it's probably coming late to LAHRS. Can we do something to make sure that you get PFA soon so that the learning curve to train people can be shortened? What do you think about, you know, things like that? And number three, since CHAGAS is so important, I mean, do you have like protocols that can be shared from all of you when a patient comes with CHAGAS, we do A, B, C, and D all the time or everybody's doing whatever they feel appropriate? So that's something that, you know, we can start with each of you comment and then we can ask. I want to invite the panelist, Juan Carlos Serpa, and Carlos Guzman from Mexico. And Jose Lorente is not here. That's it. Well, he says Luis Carlos is not coming. Then I invited Luis Aguinaga. Yes, Luis Aguinaga. Perfect. So, I mean, I already made a provocative question, so we'd like to hear from each of you. You know, Marcio, if you want to start, and then Nestor, and then all the panelists. Thank you, Luigi. I think that as I saw the presentations, I noticed that there are many things in common and there are many things that are all different. And obviously, the technology is an issue, but I really don't know how. I think that this kind of forum is important for us to figure out how can we improve technology access to our region. I think this is important. And formation, because I noticed that many countries, they don't have possibilities to form physicians. But if I may, I would like to call the attention for a step earlier, let's say, because I think that we do not have data. I think that we really should have data in our region. It called my attention that some countries, like Argentina, is trying to do so. There are some other countries that do have data on implants, but there is no, let's say, formal way of doing it. I think this would be a good way to start to make a registry of arrhythmia and centers in our region so we can have this data and we can measure the things we can do from now on. I don't know how HRS or the companies could help us on doing this. I think that the companies are always important because they can help support the cost of something. But if we leave this in their hands, of course they're always going to report the data the way they want. So I think they should be asked to support registries. I think it's important that maybe the whole LHR has come up with a registry. Like we saw in this presentation, it's been very good. How many PR for each country? How many years of training are necessary versus not necessary? And then start to build up a real workflow of things that go there. For example, we know for ablation, PFA will be a hot topic during this conference. If supposed to be the way it looks like, it should reduce the experience of the operator. Of course you need to know how to get access, you need to know how to do transeptal. That part, it's RF or cryo or PFA. You need training for that, no matter what. But once you get there, for sure PFA will reduce the operator experience. So I think this technology should be expedited rather than delayed. Problem is, this new energy comes at a higher cost than the prior one. And the company, I'm talking, they are not even going to want to invest in Europe, because the reimbursement in Europe is not as good as U.S. So they are focusing on investing only in U.S. So I think we cannot practice medicine in a way that you have country A and country C where technology are separated. So we need to create, I think, important rules for the industry in where the technology are available. But before I give the word to you, I mean, I think we should, yes, is it possible you think that HRS can't have every country forming kind of registry? And this registry have to be, first of all, how many procedures are done? Like we saw, everybody collected data, but they have to be in a formal way. And then from there, atrial fibrillation, and then atrial fibrillation, what is deletion set done today in paroxysmal versus persistent in the majority of the Latin American? I think there's a lot of data that come in, a lot of scientific opportunity. So I think this is a good way. Now what we can do from U.S. is try to support this registry and try to ask with you to the industry to support the registry and probably receive the data, have somebody from our side that collect this data and review with you. I mean, probably this is a good start. I don't know the opinion of the panel. I want to break the ice and break the idiomatic frontier of Spanish and English. Maybe if you don't have any problem, turn to Spanish to get more people involved. Okay, Luis, you understand very well Spanish and Portuguese, no problem. In Spanish? Yes. Okay. I totally agree. I think the first thing we have to do to solve a problem is first to know the magnitude of our problem. And in Chagas, and in auricular fibrillation, and in resources, and in invasive electrophysiology, from what I heard, we have more or less similar problems in Latin America. The question is very good, and I'm on the board with you, with Eduardo and others, and we always comment on how we can help, or how Harbin Society can help us in Latin America. Without a doubt, our problems cover much more than scientific societies, right? They cover governments, scientific societies, health ministries, etc., etc. But what we can do in the world of science is a lot. It's good to get together here, it's very good to know our problems, but also actions on-site, right? In our place, in courses, training. There are very few people who can come here. In the last time, and I speak for Argentina, for example, the inflationary problem is tremendous. Very few have come this year. Very few have come today. As we have noted, and we commented on this with our colleagues, we need fundamental education actions in our places. Recently, and I showed you today, we finished this auditory fibrillation register, where there are great deficiencies, right? Almost 10,000 patients in a country that is now going to start for all of Latin America, where there is the scarce access of patients, for example, to complex interventions, or not as complex as simple anticoagulation. But it is also very noticeable the lack of education of doctors, the lack of education of patients, the lack of education of society to improve these conditions. I'm talking about auditory fibrillation. Chagas is exactly the same. So, we need a census from all over the country, with a total number of electrophysiologists, the total number of necessary training, and to speak with the health society. In America, we have 7-8% of ablation compared to the diagnosis of auditory fibrillation in America. How much is the percentage of ablation of auditory fibrillation in Latin America? Less, or how much less? Less than 1%. Less than 1%. So, this is a name that a government has to understand, that it is not possible that there is such a big difference. It needs to provide support. American society also needs to provide support with training, with education, with remote education, but Latin American society needs a kind of global document that all governments of all nations will support. It is not possible. Sorry, let me speak in Spanish. I speak for Mexico. In Mexico, there is a population of around 130 million people. 70% of the population has social security or some kind of social security. 20 million have health insurance, who have practically no problems with the service. And now, with the changes, around 40 to 50 million people have lost access to security. We can say that simply in Mexico, there are three different Mexicos that are very similar to Latin America. The north, the south and the center. And they are practically all concentrated in the center, which are Mexico City and two extra cities, in Guadalajara and Monterrey, which is where I work. The rest of the cities and the population probably do not have electrophysiology services. And those of us who can travel, we have had to invest in our work tools. We buy the polygraphs because they do not exist elsewhere. Here, one of the doubts is what happens with the equipment, if it is possible to use reprocessed equipment, if it is allowed to use reprocessed equipment. I think it would be very difficult to have a global focus of the whole country, which I think would be the same as Latin America. And I think seeing it by regions, northern region, Mexico, central region and southern region, would probably be very different in terms of results, approaches and types of arrhythms that are seen. I can speak for the north and in the north, fibrillation is what we do the most, chronic or paroxysm, and we have insurance for medical expenses, practically 80% of the population in Monterrey. And our charges or our insurance authorizations are based on the CPT codes, which is very similar to the United States. I think in Colombia they had another type, but it is organized by codes for tabulation of the procedure and for the authorization of the procedure. The rest of the country, it is very difficult to standardize the procedure and the payments. And the other is that I do not know if it is possible or if it is allowed in some cities or in some countries, the reprocessing of materials. Thank you. Juan Carlos. Luigi, we were talking about a problem of pulsed speech, which is a new technology that is going to be available and that promises many things, but we are in the reality of fighting with the intracardiac echo. So trying to make a general use of intracardiac echo until now is a big problem for the cost. New technologies that are little used are going to have a fairly high cost and are going to be little available for the general population as well. So, yes, we have a big problem and a very heterogeneous population in all of Latin America. But recognizing the problems we have and trying to identify them and approach them to make those interventions that improve the part of the treatment is necessary. Starting with a record, as we did with the record of the DECA, which showed how many implants were made, complex prostheses, prostheses for shock treatment, and we knew the reality we had and that until now remains. So through LARS we could also have an initiative that recognizes how many are our problems, who are we willing to get together to be able to make those interventions and be able to work. And yes, we hope that Pulse Field Ablation arrives soon, but we have other things before and we know that it will take a little longer to get to Latin America. But really this initiative, the idea of this initiative, first is to see through HRS, through LARS, to see what our reality is, what our differences are. And really, as you saw in these first talks, it is very different, country by country. So these differences have limited us in many situations. What would be the next step? And I think that's where a lot of effort from LARS goes. Document these differences, have a record, as I said before, of how many electrophysiologists there are in each country, of how many centers there are in each country, of what the possibilities are, of how the industry is involved, what industry we have, what is the monetary capacity, and do what we have to do. Each government in Latin America, as you know, is very different. Some have more support from governments than others, but in general there is little support from governments in Latin America. So I think what we have to do as doctors is register, give information and that this information is seen by many people. And relations with HRS, I think for us it is very important, because obviously Latin America, historically in everything, not only in medicine, always goes a step back. So this is part of the idea of ​​this initiative, to see what we can do by seeing and establishing our differences. But if I think about it, I think that training is the most important thing, because when I look at the step brand, the step brand needs a little less training. And you have many doctors who can implement the step brand. The difference is that the cost of the step brand in the United States is higher than in Latin America. But you have the availability of the step brand. So the industry, in my opinion, if you have more people available to do the procedure, I think it will reduce the cost. If you don't have many people available, fewer people can do the procedure, it's more difficult. So it's a problem that needs a different solution. But one solution is that more people need training to do the procedure. If you don't have people for the procedure, the cost is always high. As for training, I think that what we are doing is polarizing the specialists in arrhythmias, because we are giving, or they are giving proctoring. You are a proctor of this, a proctor of the other, and you are limiting the proctoring of the ear, the transceptals, the mapping to certain people. And there, it's polarizing, I hope it's not the case for me, but it's polarizing people who are lagging behind in the new technologies. How to do, on behalf of LARS and the Harry M. Susayeti, something to re-update us? And that the proctoring is not required, but to prepare us. I think the solution is not to bring a proctor to help us do something and you don't touch it again. I think we have to return as an education to those who lack preparation, in some center in Latin America, or in the United States, in fact. Any questions from the audience? I have a comment on that. Can I make a comment on the issue of training? ECHARES has now started, and has called doctors in Latin America, an initiative to make the new guides on global training with the European Society, with ASEAN Pacific and with Latin America, precisely because of that problem. I think it starts, I don't know if Michelle is here, but I think it starts in two months. I think that's very important. Global documents. We all know that knowledge is unique, right? And it must be applied in all latitudes. To have global guides, world guides, to apply in our latitudes, avoids things like what happens in some countries, and I talk a lot with the Uruguayan friends, we have a lot of connection. It is impossible that there is a regulation, an indication, different from the rest of Latin America. I know it firsthand, and my friend Alejandro Cuesta has always brought it here, to that concern. That's why we must have all this global regulation, and say, no, I sign it, I subscribe it, and this is also for my country, this is for Latin America, this is for Europe. So the training guides are coming now. We only have a minute, if anyone from the audience wants to make a contribution. Eliane? Microphone, please. Okay, you can... I can speak. Eliane Mejia, Dominican Republic. First of all, this is my first time in a meeting like this, in Latin America, and I congratulate the organizers, because it is the first time I meet people from different latitudes, and I think that after listening to each of the colleagues, we have more similarities than differences. In fact, each one was an echo of the problem that we represent. In those same differences, two aspects caught my attention. Number one, the costs. We can't be good if we don't have the resources to do it. How are we going to be successful with a ventricular ectopia, with a papillary muscle, if we don't have AIS? It's almost like throwing ourselves into the blind. So, if we don't work on what are the technological limitations, and resources, we won't be good. And in that same aspect, the limitations that we have in Latin America are our numbers. Our numbers are still low. So, the industries won't lower the costs until we have bigger numbers. So, if we don't unite as a Latin American region, where all our numbers are shared, and we talk through action policies, or political action committees, that we can do together with HRS and LARS, where together, our numbers, after the census that Luigi talked about, those numbers are unity, where we present the industries as our highest numbers, as a Latin American region. So, yes, the costs will go down. On the contrary, individually, seeing the numbers that we present, the costs won't go down, for ventricular ectopias or for AIS. We will be a few people who pay in private, and most of our patients won't benefit. The second aspect is the education aspect. I understand very well why none of the fellows still train in the country. Again, the numbers. We need a lot of casuistics to be able to have fellows educated in local countries, and we need many years for this. Now, what do we need? In Latin America, we work alone. We don't have nurses trained in atrophysiology. We don't have trained mappers, and this is a huge limitation. When many of us and colleagues can do this, when we are going to do complex cases, we have to schedule this mapper to come to our center, and come from Puerto Rico, or end up in Costa Rica, to come to us, which limits our schedule. So, if we don't work hand in hand, all Latin Americans, with the industry, so that our numbers are shared, so that they know that we are strong, and that if we share the numbers, then the demand will be higher, the costs will be lower, and we will have a better representation at the level of procedures. We don't work alone, and we need mappers, above all, before increasing the number of atrophysiologists. We have to work more coherently with what we have. Thank you very much. The last question. Let's go to the break. Yes, thank you. Mauricio Hong. I work in Austin, but I am from Mexico City. Looking at the numbers, the number of defibrillators that are implanted in Latin America is minimal. So, I think that something that we can do right now is to start doing the stimulation of the left branch, in marcapaseo, which we started, and I started doing it a year and a half ago, and the fraction of injection is going up. Right now, I spoke, there is $3,000 less between a bicameral marcapaseo compared to a resynchronization marcapaseo, and compared to a defibrillator, $15,000 less, and if the fraction of injection increases with the left bundle pacing, then we are saving $13,000. It is the lead, 3830, of Medtronic, which is available for all of you. I think we have to start training all Latin Americans to put the stimulation of the left branch, today, because that is available right now, and this will reduce the number of defibrillators we need. That is point 1. Point 2, for Chagas, my wife is an infectologist, and malaria, the case of malaria, Bill Gates, the association of Bill Gates, has almost eliminated it, almost, so I do not know if HRS can talk to the association of Bill Gates, for the association of Chagas, because it is something that he is interested in, that his association is interested in making that kind of contact. So, I think we make a document of HRS with Bill Gates, maybe we can have an influence for Emilio Chagas, and good the third, in terms of teaching, I am open, true, being Latino and working in United States, to help in what I can, I have tried to speak to Mexico, Colombia, to certain countries, there are limitations also of Latin America when we offer our help from the United States and these limitations are generally of ego, of arrogance, and I think we have to get rid of that, right, because I am open to coming fellows from all Latin America to my place, to put, to LeBron Lopez, that we can start the month that comes in, ok, and also to send people to train in the United States and the problem is that they come back for there, right, but well, thank you. We move on to a small break of five minutes, fast, and see you again. Well, first of all, I want to invite the President of HRS, I want to introduce Andrew Clarn, he is the President of HRS, he really was a great support for us, for HRS, for Lars, and we are so grateful with him and all the effort he has been doing. Andrew, please, you have to... Please, please quieten the crowd. Por favor, los invito a sentarse nuevamente, silencio, por favor, va a hablar Andrew Clarn, el Presidente de HRS, que es un honor tenerlo con nosotros. Well, thank you very much, Nestor, it's a real privilege to be here. When I went to Campinas to the Lars meeting, I had several days where it was really such a welcoming environment for the community to welcome the President of HRS and also get to know some people, and I think it speaks to the partnership that we've been working on together as organizations, and I credit Fred, who will make a few comments, Fred Kusumoto at my left here, with the idea of formalizing the process of partnership and creating these summits to try to understand both the organizations but also the process of care and our joint interest in improving the process of access to care and quality of care, and that's through initiatives like not only technology and health systems but education and partnership and communication and joint publications and committee work together and so on, so I think all of these things speak to our common interest in building together, and I'm very grateful also to Nestor for making about a hundred phone calls to people to bring it all together with support from Michelle and Ulysses for his role and leadership of Lars, so I, the timing of this was related to when people could feasibly travel and so on, and so I'm actually in the middle of running a board meeting over on the other side, so our board's meeting, so that's why I haven't been able to be here for the whole thing, and so Fred and I are going to say hello and then graciously try to excuse ourselves, but once again, thank you for the invitation and the opportunity to build our friendship. Fred. Yeah, just, you know, the excitement in this room is just, you know, it's palpable. It's really exciting because, you know, as Andrew just pointed out, you know, arrhythmia care is worldwide, and so this notion of trying to build a worldwide community is absolutely critical, so last year we started with Asia-Pacific, so we had the APHRS and HRS had a joint summit similar to this, and that actually is going to come to a publication coming out in the next month or two, and I know that proceedings from this meeting will have that same sort of impact, and what is that impact going to be? Is it going to be a lot of people just talking together? No. What can happen, sort of, with that? With that APHRS-HRS summit, we actually have, for example, how much funding does, let's say, Japan or Singapore do for cardiac care, for medical care? What percentage of their GDP? And I will tell you, there is no question in Asia, it is really quite variable, no surprise. I think it is a similar situation in Latin America, and I think that this kind of information, this sort of evidence, Eduardo and I were speaking about it earlier, this type of evidence can put real pressure to then make real change, which then, ultimately, will then provide additional care, better care, for all of our patients. Similarly, thinking about pacemaker implantation, which, as we were talking about, that's an emergent, see, but how about three-dimensional mapping, defibrillators, CRT, things like this. We have those numbers in Asia. I hope that you are going to put those together for Latin America. This type of real evidence and information can then be used to inform governments with regards to how to fund the care for their patients, so that the best care can be provided in your individual country. So this is something that is not for nothing. This is something that is for something that can really impact change, and that for all of us, then, ultimately, as Andrew just emphasized, to learn from each other, to identify best ways to go forward. So thank you very much for letting us be here. Well, we'll start the last part of the event, and I want to thank, thanks. Well, the first speaker will be Alejandro Cueto from Argentina. He's the president of SADEC. After him, Juan Lopez-Diaz, president of the Committee of the Argentine Society of Cardiology. After him, Gerardo Rodríguez from SOMEG. Juan Carlos Díaz, a large representative from Colombia. Armando Pérez Silva from Chile. And Fátima Dumas, president of SOBRAC, the Brazilian Society of Electrophysiology. Please, the videos. I'm going to speak on behalf of Dr. Alejandro Cueto, cardiologist, electrophysiologist, president of the Argentine Society of Cardiological Electrophysiology, SADEC. First of all, I want to thank the invitation to the Latin American Society of Cardiac Rhythm, LARS, and HRS, for participating in such an important event at the Latin American level. As for the number of electrophysiologists in our country, in Argentina, there are around 750, based on the data of the last four Argentine electrophysiology congresses . The majority, 72%, are in the city of Buenos Aires and the province of Buenos Aires. What are the official requirements or credentials? Well, they are those that emanate from the resolution of the Ministry of Health, and for this we must present a series of documents, where there is evidence that the aspiring person has participated in the analysis, discussion and decision-making of clinical cases related to arrhythmias, has interpreted at least 500 halters, has carried out 100 tin tests, and has also controlled, monitored, programmed at least 100 step markers, 30 defibrillators and 15 desinfectants. In addition, he must have at least participated in 100 electrophysiological studies, 50 radio-frequency talks, and have participated in the implantation of 50 macapazos, 30 defibrillators and 15 resynchronizers. As for the offer, the presence of opportunities for training in Argentina, there are many, and there are entities and various associations that give opportunities and courses. One of them is SADEC, the Argentine Association of Cardiac Electrophysiology, which is the headquarters of the University of Electrophysiology of the National University of La Plata and grants the title of Electrophysiology Specialist and Step Marker. It is also done by the Universidad de la Fundación Juan Valoro, and the Argentine Association of Cardiology performs the higher course in Cardiac Electrophysiology. As for fellowships, there are many, most of the centers offer these opportunities, and mostly come to Argentina, doctors from their own country, from Bolivia, Ecuador, Colombia and Uruguay. What are the entities that group Argentine electrophysiologists? Well, the Council of Electrophysiology of the Argentine Federation of Cardiology, the Council of Electrophysiology of the Argentine Association of Cardiology, and the Argentine Society of Cardiac Electrophysiology, SADEC. Is there a national congress? Yes, there is the Argentine Congress of Arrhythmias, which is organized by SADEC and the Arrhythmias Committees of the Argentine Association of Cardiology and the Argentine Federation of Cardiology. And it is one of the largest electrophysiology congresses in Spanish-speaking countries. The last congress, the eleventh congress, which was held last year, in 2022, had 3,160 members, most of them doctors, from 10 countries, and mostly women. What are the scientific activities of the SADEC? Participation in multiple webinars, navigator courses and intracardiac echography, annual course for technicians in step-markers, defibrillators and resynchronizers, electrocardiography and Holter courses, and joint activity with the World Association, the Argentine Federation and the Argentine Society of Cardiology. There is no gremial activity or direct relationship with the government. As for the availability of technology in the Argentine Republic, there are multiple 3D mapping systems, both from Abbott, Johnson & Johnson, and Microport Everplace. There is also the availability of cardiac echography, but it is mainly made in patients who have private health insurance, less in patients who have social, gremial insurance, and a very small number in public hospitals. What are the activities in the development of Argentina? Everything that is step-marker implantation without cables, physiological stimulation, and the use of OREJUEGA occlusives. Thank you very much. My name is Juan Cruz López Díez, and on behalf of the Argentine Society of Cardiology, I am going to talk about the medical system in Argentina. The Argentine health system is made up of three subsystems. These are public health, social security, integrated by national, provincial and retired social workers, and pre-paid medicine. The public health subsystem provides universal and free health coverage in hospitals and assistance establishments to which every citizen has the right to access, regardless of whether they have other types of coverage, such as social work or pre-paid medicine. Its financing comes from taxes collected at the national, provincial and municipal level. In the public system, there is no defined and homogeneous loan plan for the different hospitals, so the supply of health services depends on the availability of health personnel and their specialties, equipment, supplies, available beds, availability of shifts, etc. The availability of these resources is very variable throughout our extensive territory. In many regions, it is common for the demand to exceed the supply, so there are huge delays in the granting of shifts or lack of specialties in some establishments. The public sector is used by approximately 36% of the population, and these are people who do not have any other type of coverage. It is remarkable that in this system foreigners are treated, even those who are not naturalized, for free. Social workers. Social workers in Argentina are entities that provide medical care to workers in relation to dependency. They can be state or private, although the vast majority depend on trade unions. Social workers are equivalent to the medical insurance of other nations. By law, all employees in relation to dependency must have medical coverage, and for this reason the worker and the employer are obliged to pay a percentage of the salary for this purpose. Social security is the main source of non-governmental health coverage in the country. There are almost 29 million people, which is equivalent to 63% of the population. The private system or prepaid medicine. Prepaid medicine companies are private medical institutions for profit, used by a sector of the population that can absorb the cost of a monthly fee. 13.6% of the population enjoys this luxury. As you may have noticed, the percentages exceed the total population, and this happens because there is a superposition of coverage with people who have at the same time provincial and national social security benefits or social and private security, since the different health subsystems are not articulated with each other. I mentioned initially that in the public system there is no defined and homogeneous set of benefits for the different public health hospitals and establishments. Now, social workers and prepaid medicine companies have the obligation to comply with the benefits established by what is called in Argentina the mandatory medical program or PMO. This contains the set of medical benefits that all beneficiaries of social security have the right to, and everything associated with prepaid medicine. That is, it constitutes the set of mandatory medical benefits that, as a minimum floor, must be provided by health insurance agents and prepaid medicine companies. The PMO guarantees to have covered 40% of the cost of ambulatory medicines and 100% of medicines in hospitals and oncological medicines. In conclusion, Argentina has outstanding health virtues, such as inclusive principles through universality with respect to coverage. However, serious flaws are observed in the facts. Today, in many places in the territory, access to health is not guaranteed, and when it is, the quality of the service is not homogeneous, since it is determined by the purchasing power. This is because the health system is strongly fragmented, generating a lack of coordination that dilutes the responsibility when it comes to providing coverage. The PMO seeks to grant guarantees of equal coverage for any beneficiary. In practice, social works have differences in issues such as the administrative attention provided, the availability of shifts, the offer of professionals and the closeness of beneficiaries with care centers, which generates that there are different qualities of services that, as always, are reflected more intensely in the sectors furthest from urban centers and with lower economic resources. Thank you for your attention. In order to make myself clear. There are systems that have two or three different insurances. The largest system is the IMSS, which is the Mexican Institute of Social Security, which is based on contributions from workers and government contributions. It serves around 70 million workers. The ISTE, which is the Institute of Social Security at the Service of Workers, serves around 14 million state workers. The Armed Forces, which is the Army and Navy, 1.5 million. And the Ministry of Health, and now a new system has been incorporated, which is the IMSS Welfare, which is also from the Ministry of Health and serves 40 million workers. Some people have two or three coverages between IMSS or the Armed Forces, ISTE or the Ministry of Health, or even private media or systems. Within the private health system, what do we have? Well, insurance policies, because the minority of the population can pay for procedures, and above all complex and expensive procedures, such as electrophysiological procedures. There are around five different policies or more. So that's complex because we don't know what the insurer is going to charge, to cover in their policy, and how much the medical fees are going to be. So the coverages are different. The procedures cannot be added either. The function cannot be added with the transeptal function, with echocardiography, etc. They only catalog a single procedure. And besides, these medical fees are undervalued. Private hospitals, there is no official rector in the whole country. Each private hospital is governed by its own individual rules. And besides, the country is very heterogeneous. The population has a different purchasing power. It's not the same in the south, in the north, in the center, and it's not the same in the border states, etc. So the high specialty is generally concentrated in urban centers. But there are states that are important, like the state of Veracruz, which does not have an electrophysiologist in the whole state. So you have to go outside to do the procedures. As for the public system, the public system has three fundamental problems, which is fragmented and dispersed. There is a brutal administrative bureaucracy and the problem of wages. It is fragmented and dispersed because there are three large health systems, but each state can have its own health system for the workers of that state. So this gets very complex because there can be ten different health systems. And there is no coordination or joint plans between each system. Here we are going to see it. The IMSS, the ISTE, and the Ministry of Health, which are the largest organizations, have independent directives and do not have mutual collaboration. That is why the Ministry of Health, which should govern the country's rules, does not. The high specialties are also concentrated in a few centers, and there are some centers where electrophysiology is not recognized as such. We have a nomenclature as hemodynamists, not as electrophysiologists. And there are also few electrophysiologists at the national level, approximately less than 200. And not all electrophysiologists perform the same procedures. The administrative bureaucracy in all of Latin America is brutal. The transfers to the high specialty reference centers are complex. And in addition, the indicators are not based on the quality of care, but they are based on numbers. Numbers such as if you attended a patient in less than a month, but it is not seen if you solved the problem for him. The bed days are not counted. And a hospitalized patient may be waiting for a pacemaker to be bought. Budgets are labeled and individual. they cannot be mixed. We can have supplies for a desynchroniser, but we cannot have gas or antibiotics. Finally, the salary and benefits. Each health system has different salaries and benefits. The best is the IMSS system, which is the Mexican Institute of Social Security, and the worst is the ISTE, the Social Security System, the State Employees' Service. To give you an idea, a month's salary in a public place like the ISTE is equivalent to a private procedure, a passport stamp placement in a private place. So it's very complex because there are places where they don't want to work in the public system, even though there are cardiologists or electrophysiologists, like in the border, because the payback is very low and there is a lot of paperwork. Finally, I want to say that despite all the restrictions we have, there is a success in the treatment of arrhythmias in Mexico and it has evolved in the last 10 years. Everything is done at an international level. Ear inflation is done with cryo and radiofrequency, physiologic stimulation, hyssian, desynchroniser, defibrillators, simple and complex ablations with CARTOS system, zero-fluoride, or with ENSITE system, ventricular tachycardiasis, etc. Despite the shortcomings, we do have equipment and we can carry out studies satisfactorily. Thank you very much. Good afternoon, everyone. My name is Juan Carlos Díaz. I am a cardiologist and electrophysiologist from Colombia. The idea is that we are going to talk a little about the Colombian health system and what the challenges of electrophysiology in Colombia are like. I have no conflict of interest for this talk and the idea is that we start by talking a little about the Colombian health system. Currently, we have three regimes. One is the contributory, which are those people who have a monthly salary and we give part of our money to contribute to the health system. Another is the subsidized, which are those people without the ability to pay, who, in theory, have the same benefits and the same rights as those who pay for the health system. And there are the special regimes that are part, for example, of the teachers, psychiatrists and the military forces. There are several actors in this. One is the government, which is the one that sets the policies and how the payment will be for each year of the health system. The health care providers, which are basically the insurers who are going to manage the money that the government gives them. The health care provider institutions, which are the clinics and the hospitals that are going to contact those health care providers and the health professionals, who are the ones who are going to end up providing the service. The cost of health in Colombia is relatively high, which is approximately 8% of the gross domestic product. And the pocket expense is minimal, with almost universal coverage, with what we call the basic health plan. That basic health plan includes 97% of all available technologies in Colombia for all areas of medicine and 89% of medicines. This in electrophysiology translates into that we have the possibility, through this basic health plan, to do medical consultation and device interrogation, to implant any type of device. In addition to that, all electrophysiological procedures, including conventional studies and three-dimensional studies, and it does not cover remote monitoring, which is a felt need that I think we are all having at the moment. At present, we are 64 members already in the Colombian College of Electrophysiology. There are three who are in the process of entering and there are 10 electrophysiologists who work in the country who are not and are not part of the Colombian College of Electrophysiology. As you can see, the vast majority of electrophysiologists work in large cities such as Bogotá, Medellín, Cali and Bucaramanga, with a lower representation of what is the interior of the country, towards the coffee plant, the south of the country and the Atlantic coast. How is the process to become an electrophysiologist? Well, first you have to have three years of internal medicine, then two years of cardiology and then two years of electrophysiology. And this applies both if you are trained in the country and if you want to complete an external degree. The completion of an external degree requires that it be a degree given by a university and that these requirements are met in the training program. The vast majority have been trained in Colombia with some people trained in other places in the world, but in Colombia we currently have three training programs, one in Medellín and two in Bogotá, and approximately six fellows will graduate each year. What are these fellows trained in? Well, they are trained in devices, in conventional studies, that is, those with fluoroscopy, and in procedures with three-dimensional mapping, such as pulmonary vein isolation, ventricular tachycardia ablation, ventricular atrial extrasystoles or atrial tachycardia. That is, the fellows in Colombia are trained in practically all the procedures that we can do today in electrophysiology and they have good training compared to fellows from the rest of the world. What are the future challenges? I think this first challenge that I raise here is a challenge that is common for everyone and particularly in Latin America. We have to take the step forward to modify it and that is to increase the representation of women in electrophysiology. There are many fears among women. For example, exposure to radiation. It must be explained from the basic training programs that many of the procedures are currently done with minimal radiation or even without fluoroscopy. It is necessary to facilitate spaces for those women who are head of family or who have children, and it is necessary to have a change in the attitude of some teachers who still consider that electrophysiology is not an area for women. It is necessary to expand the provision of the service in intermediate cities and, in addition to this, we must start telemedicine programs that allow all these areas that do not have electrophysiology to provide highly specialized and quality care. Thank you very much. Good afternoon. My name is Armando Pérez Silva. I am a cardiologist and electrophysiologist at the Regional Hospital of Concepción in Chile. I would like to thank L'Arche and HRS for this kind invitation to share a little of our regional experience. Well, I have nothing to declare. Chile is located in the south of South America, adjacent to Argentina and Bolivia, and with the Atlantic Ocean. It has a very different geography from the rest of the region, with deserts in the north and very cold climates in the south. And given this particular geography, many of its health policies can be explained. It is important to remember that it occupies the 33rd place of almost 200 countries in better health quality and can be compared with many countries in the Iberian Peninsula. It invests an important part of its gross domestic product in health, one of the highest in the entire region. It is estimated that this investment is around 9 to 10 percent and is administered by a national health system called FONASA, which is in charge of following specific health policies. It is also estimated that two-thirds of the population are within the net public system and only less than a third are in the private system. The life expectancy in Chile has increased in recent decades, being low in the mid-1950s, to be currently the highest in South America and is expected to be the highest in the continent by 2100. And this is mainly due to several policies, but the most important of them, and those that affect heart rate alterations, are the GES pathology and another call for emergencies. The GES diseases are a set of 87 pathologies that include from pneumonia to different types of cancer, where heart rate alterations are included, bradycardia, tachycardia, all kinds of step-marker implants, and these guarantees, this type of pathology, this law makes that any patient who has any of these diseases is an obligation of the state to comply, follow up, and also in a pre-established period of time. And the law of emergencies is a law that is explained in other parts of the continent as well, but what it tries is that any patient with a life-threatening disease, regardless of their public or private condition, or regardless of the type of health system they have, the closest public or private health center must solve the pathology in a complete way. As I said before, all bradyarrhythmia problems, specifically any type of step-marker implant, occur practically throughout the entire geography of the country. This is an important point compared to other countries in the region. We are clear that in many places in the South American continent there are countries that simply do not have access to a step-marker implant. Here in Chile, it is very difficult to say that a patient dies or dies due to a lack of a step-marker implant. In other words, anywhere it can lead to a nearby region or in its own region and a step-marker implant is implanted. Not so the alterations due to tachyarrhythmias or complex arrhythmias, or patients requiring defibrillators, resynchronized conversations with the navigator. Here, almost two-thirds or more of all these pathologies derive from a very small area of ​​the country, which is the central area, the south-central area of ​​the country, where almost all the procedures derived from other health centers are carried out. This is mainly due to the lack of development of complex hospitals in the very extreme areas of the country. As a conclusion, I must say that Chile is developing as a country with promising and innovative public health policies, but the accidental geography, the low population density in the most extreme areas of the country, desert and cold to the south, and coupled with the lack of specialists in these regions, has been a substantial limitation for complete development. Thank you very much for your attention. Brazil is the only country in South America and also Latin America with more than 2.4 million inhabitants. It is divided into five regions with great differences, not only in ethnics, culture, but also in health assets. The current structure of Brazil's health care system is called Sistema Único de Saúde, and was implemented in 1988 and established health as a universal right for the whole population with three main principles. The first one is that universal rights include all levels of complexity, primary, secondary, and also tertiary. The second one is decentralization, thus involving federal, state, and municipal governments to provide health. And the third one is a great social participation, not only in formulating, but also in monitoring implementations of health care policies. Nowadays, the private health care becomes an important pilot of sustainability of health care services in Brazil. It is responsible to serve more than 23% of our population that corresponds to more than 15 million Brazilians. It becomes an alternative for obtaining health care services, and it gains attention not only by the amount of service offered, but also by the quality of care provided to its users. There are three main ways to have access to private health care in Brazil. The first one is personal health insurance. The second one is a company health insurance for those who are employed by a great company. And the third one is a professional association health insurance. It's kind of personal health insurance, but with a very attractive price, since the negotiation is made by a great number of users. It's clear that the public service represented by Sistema Único de Saúde will not be able to meet the demand of medical care in Brazil. So it's expected great challenges in Brazilian health care system. The first one is inequality in access to health. We can deny that many measures of health care systems performance in Brazil have improved since SU's implementation, but again have not been equal across the population group. Another point that should be highlighted is a great demographic transition. Life expectancy in Brazil increased from 70 years old in 2000 to almost 76 years old in 2019. It's a good result, but still some years remain some years below when compared to similar countries. Access to highly complex procedures in Brazil is the main challenger, especially those related to cardiac arrhythmia. According to Brazilian mortality information system, from 2080 to 2019, there were over 350,000 hospitalizations for atrial fibrillation, but only 14, 13 ablations procedures for AF performance by SU's. And despite the great reduction observed during pandemic, we currently have about 20,000 space makers implantations and 7,000 electrophysiologist procedures, far below what would be expected. It is also important to address material reprocessing, and at this point requires a more comprehensive discussion. In Brazil, reprocessing EP materials is heterogeneously managers across different states in the country. And although federal regulations allows reprocessing, there's a lake of national protocols, structure and data that indicates safety of this practice in the country. I hope I have clarified some important points of the Brazilian healthcare system, and thank you very much for your attention. We'll speak from Uruguay, Alejandro Cuesta, large representative. After him, Eliani Mejia from Dominican Republic, in representation of the Peruvian Society of Cardiology, Ricardo Segarra, and then Ana Gonzalez Luna from Peru, and Eleodoro Rodriguez from Venezuela, in representation of the Venezuelan Society of Cardiology. To end, from Salvador, Marta Reyes, and Elibet Chavez from Cuba. Good afternoon, everyone. My name is Alejandro Cuesta. I'll briefly explain how the National Integrated Healthcare System works in Uruguay, and then Dr. Banina will speak specifically about the electrophysiological area. Our healthcare system, which has been integrated for 15 years, is at the national level. It is based on four basic principles of sustainability, universality, equality and quality. Sustainability is determined because this is organized from the government, from the parliament, and the pillars are the Ministry of Health, the Ministry of Economy, the Ministry of Economy providing sustainability, responding economically to the system, and the Ministry of Health as a health authority, ensuring and supervising quality. This national system integrates all public and private actors. Some are very small systems, such as the military system, the police, the university hospital, and the national mobile emergency system. The National Integrated Healthcare System has, on the one hand, its governance and financing. The governance is given by the National Health Board, integrated by the Ministry of Economy, the Ministry of Health, employees' delegates, employees' delegates, employees' delegates, and users' delegates. This is the political control of the system administered by the National Health Fund. This National Health Fund is fed by contributions from all workers, from all employers, also from retirees and state contributions. In addition, there is a sub-fund that is for high-complexity and high-cost procedures, which we will later extend. This National Fund is the one that finances integral providers through capital, that is, it pays a fixed amount per affiliate, according to the sex of the age, and it also pays according to certain benefits goals, for example, breast cancer screening, colon cancer screening, maternal lactation, etc. This is done through a contract. The National Fund makes a management contract with the integral providers, and there it is forced to lend a basket of health benefits and a basket of drugs, which is roughly the vast majority of the benefits, but not all of them, if it is the equivalent of our system. It also receives other lower income from contributions by tickets, from some private insurance quotas and from the sale of services. And then there is that smaller sub-fund, with the exception of the high-complexity procedures, of lower frequency and more expensive, where this fund itself establishes what the mandatory benefits are. And here they enter, as they will later tell you, most of the electrophysiology procedures, or should enter. Then the users of the public system, who opt for the public system, do not pay anything at all. Those who opt for, within the integral providers of collective assistance, those pay only tickets. Those who opt for private insurance have to, in addition to repaying the tickets, a surplus above the capital that the National Health Board gives to the company. And the benefits of the National Resource Fund, for example, a heart transplant, a heart surgery, a defibrillator, for this they do not pay anything and it is universal. It covers 100% of the population. Everyone has the same rights and obligations within that framework. Then, of the Uruguayan population, 39% opt for those integral providers to attend the public system, because there they do not pay tickets. Only 1.8% behind private insurance, because there they have to pay a surplus, and 57% or 60% of the evaporation is obtained in the system of collective companies, which are usually co-governed, in which only tickets are paid and, well, the quality is an intermediate quality between the other two subsystems. And regarding the procedures that are done in the highly specialized system , the user, regardless of where he or she belongs here, the user likes in which image, in which high-complexity center he or she wants to attend. Well, I hope that in this scheme, more or less, it has been clear to you how it works. I imagine you also have doubts, that I am sorry not to be there, but Dr. Manino can probably evacuate. Thank you very much. Good afternoon. I'm Ulyani Mejia. I'm an aortic electrophysiologist, and I'm following the presentation of my colleague, and I'm going to be talking about the political issues. We have five major problems that we're going to be discussing. Access to health care services, training and education, insurance coverage, integrated societies for electrophysiology, and standardized guidelines and protocols is the last one. Number one and major problem is the access to health services. In our country, approximately 30% of the population in the Latin American and the Caribbean do not have access to health care because of economic reasons. 21% do not seek care because of geographic barriers. In the same token, our country, as many others in Latin America, has advanced economically in the last decade. Along with this increase in globalization, the lifestyle of the people has changed. Life expectancy is higher, and with that comes an increased burden of disease resulting from chronic and non-communicable diseases, such as hypertension, diabetes, cancer, and obesity. When we talk about this, we have to talk about the health spending in Latin America and the Caribbean, and compared to other countries, Dominican Republic is right in the middle. We are not at the top or not at the very bottom. But even with this, we're still lacking resources in order to provide appropriate health care for our population, which leads to inequalities and inequities in health care, with a significant percentage of the population at the base of the pyramid. This means that many sections of the population are often at higher risk, as health care problems are often influenced by social factors such as education, sociocultural level, income, and ethnicity. The third major problem is straining education and distribution of human resources and health. Our country still does not meet yet the international indicators such as number of doctor or nurses per 10,000 people, or hospital beds available for 1,000 inhabitants. People are often concentrated in capital cities or in a few geographical areas, leaving groups outside of these areas neglected. The problem is not only the lack of resources, but also a poor distribution of them. In this same token, this straining and education translate into a lack of ancillary staff, and we see doctors in our country very often working as individuals and not as a team, lacking the ancillary staff needed to improve efficacy and safety. We lack nurses and text training in cardiology, and specifically in electrophysiology. Number four is a major problem, and it's insurance coverage. We currently have an old catalog of services that is not updated with the latest technology in cardiology, which harms the EP field development in our region. High power devices such as ICDs and CRTs are not currently covered. The same for truly mapping system, eyes, or contact forces catheters. And this translates into a high out-of-pocket cost for our patients, and limited the care of this patient, which in terms results in increased multiple procedures or hospitalization because these patients did not have the treatment that they actually needed in the first place. And this, specifically the lack of coverage for high power devices, is important and particularly striking because not even for secondary prevention, ICDs are covered in our country. And the problem is that the financing of health system. Currently, we have a system that finance their health services based on illness, which means that resources have to increase as more people get sick. This mechanism becomes unsustainable because it encourages a system based on disease and not health. And for this reason, over time, the system as well, the resources will always be limited. We are working together as an integrated societies in electrophysiology with the creation of protocols and guidelines and appropriateness criteria for diagnostic and therapeutic procedures in EP. We're working to do and we aim for a standardization of all EP labs in our country, creating a unifying force to advocate for our patients. And how we can meet these challenges, we have to integrate three areas, political, social, and economic areas in order to improve the health care in our country. And this is going to be divided in three major areas, primary prevention, secondary prevention and early intervention, and tertiary prevention or response that this is where electrophysiology lands. Thank you so much for your attention. Hi, everybody. Thanks to HRS and LARS for inviting me to participate in this Latin America Summit of the Heart Reading 2023 session. I am Ricardo Segarra, EP cardiologist from Lima, Peru. I'm going to talk about cardiac EP health policy in Peru. The cardiac EP started in 1998 at the Guillermo Almenara Hospital in Lima, Peru. The beginning was challenging, but the experience was progressively richer. In the following years, new EP cardiologists were beginning to work at different hospitals in the country. At the moment, we have in my country four independent health systems. One of them is a Peruvian Ministry of Health. Another one is a social security health system. Other is a military and police health system. And finally, private health system. For now, we are 24 EP cardiologists for 32 million people in the country. And most of them are working at the capital in Lima, Peru. All EP in Peru were training outside the country. And the EP certificate is going to be approved by the health national authority. We are making all conventional and complex EP procedures using all the tools on the market, including multi-electrode, maping catheter, contact for ablation catheter, and intracardiac echo. We don't have EP society. But extended, but extended, the Peruvian Society of Cardiology has an EP cancer responsible for all scientific activities. Finally, ladies and gentlemen, I will say the EP is increasing in Peru. Local EP training, more EP lab coming soon. Thank you for your attention. And we also have approximately 30% of the population in poverty. Within the basic indicators, the life expectancy at birth is 77 years. And within the main causes of mortality, we have cardiovascular diseases that occupy third place. The demographic transition over the years, we see how it has been decreasing the pediatric population with an increase in the adult and adult population. The main diseases, such as hypertension, diabetes, overweight, and obesity are highly prevalent in our country. The rules that govern the health sector in Peru, at present, we are based on the political constitution of the year 93, in which it is established that everyone has the right to protection of their health. In 2009, the framework law for universal health insurance was published. And in 2019, the emergency decree that seeks to close the gap of the population without health insurance coverage, seeking to affiliate the population regardless of their socioeconomic condition. The current financing in Peru is intended for total health spending, approximately 5.2% of GDP, well below other Latin American countries. However, this percentage has been increasing both in the public sector and in the private sector. The budget for the health sector is approximately 11.5% compared to the general budget. And cardiovascular diseases are among the main diseases with the highest spending in health services. How is the health system in Peru composed? Its interrector is the Ministry of Health. It is divided into two large groups, the public sector and the private sector. The public sector is made up of the Integral Health System, which is subsidiary and semi-contributive, and Social Security or Health, which is a contributory type for dependent workers, who contribute approximately 9% of their monthly salary. The third group is that of the armed forces and police. The private sector is made up of health care providers and private insurance companies. It is important to mention that in the public sector, health coverage is total. The coverage at present, we have approximately 78% of the population has some type of insurance. The vast majority, almost 48%, are affiliated with the Integral Health System and 25% with the Social Security System. Almost 20% of our population does not have any type of health coverage. The adult population, approximately 89%, has some type of insurance and almost half of this population is affiliated with the Integral Health System. Approximately, we are 44,000 doctors. The vast majority of health professionals are concentrated in Lima, which is the capital of the country, and in the big cities, where the percentage of poverty is lower. Approximately 77% of doctors focus their attention on the two highest levels of wealth. Approximately, our health establishments, in the vast majority, are medical centers and health centers, and in a small percentage, they are institutes and hospitals. We have complex hospitals, only 57. What are the main health problems? Lack of staff, lack of competition, there is a poor distribution of specialists, lack of medicines and supplies, many times the teams are poorly managed, and lack of protocols. Thank you very much. I would like to thank HRS and LARS for allowing me to participate in this Latin American Summit 2023. We are going to talk about health policies in Venezuela, fundamentally related to heart rhythm alterations. For all of us, the important social and economic crisis that our country has suffered in recent years is known, which has had a repercussion in the health sector, and this is reflected in everything related to the management of heart rhythms. The Venezuelan public health system, which serves 90% of the population as a result of this economic crisis, has deteriorated and has significant shortages. On the other hand, patients who go to the private health system depend on their own resources, private medical insurance and remittances from relatives abroad. We do not have up-to-date and reliable information on cardiovascular mortality and morbidity, and specifically on heart rhythm disorders in our country. It is important to remember the profound demographic change that our country has had in recent years. It is estimated that more than 4.7 million Venezuelans have emigrated. It is the only country in Latin America that has had a decrease in its population in recent years, and within this group of emigrants we must highlight, related to the topic we are discussing, that 30% of well-trained and qualified electrophysiologists who had a professional life in our country have also been part of this group of emigrants. All this is related, of course, to the profound economic crisis associated with the decrease in oil production, which went from 2,800,000 barrels of oil per day in 2015 to less than 700,000 barrels of oil in 2021, which fortunately has been increasing production in recent months. We hope that the economic indicators of the crisis will improve. I think it is important to take a picture of what 2015 was like. We had 12 three-dimensional browsers. Public employees at that time had a large insurance policy provided by the state, which provided coverage for electrophysiology procedures and high-cost device implants. Another percentage of the population had insurance that allowed them to access these therapies. Currently, there are only two CARTO 3 browsers and a CARTO 3 version 7 Prime system in the city of Caracas. Public employees have policies with lower coverage. However, in special cases, the Venezuelan state does not provide assistance to carry out procedures and a smaller percentage of the population has wide coverage insurance. In 2015, primary prevention of cardiac surgery was carried out on a daily basis, according to the guidelines of the guides. There was a wide supply of antiarrhythmic drugs and at least 10 public centers in the main cities of the country carried out invasive electrophysiological procedures. Currently, the Ministry of Health is in charge of supplying the devices that can be implanted in the public sector. However, the number of high-cost defibrillator and resynchronizer implants has decreased. The supply of antiarrhythmic drugs is much more limited than it was years ago and only two public centers carry out operations in the private and mixed sectors. More than 20 institutions carry out invasive electrophysiological procedures. So we can conclude that in Venezuela there is currently no reliable and up-to-date information on the mortality and morbidity of arrhythmic disorders that allows strategies to attack these pathologies. The available data comes from the opinions of a group of experts and some fundamentally public institutions, as well as the extrapolation of bulletins issued in previous years. These shortcomings constitute a barrier for strategies to solve these problems and the Venezuelan state has to give priority to the budget of the health system and the Ministry of Health must provide true and up-to-date epidemiological information so that together with non-governmental entities and scientific societies we can implement actions to optimize the care of the population. Thank you very much. Hello, I greet you, Marta Reyes, electrophysiologist from El Salvador. Thank you for the invitation to this Latin American symposium. I am going to talk a little about the health system in El Salvador. We have only three qualified electrophysiologists, that is, our certificates have been authorized by the Medical School and by the Superior Council of Public Health of El Salvador for the exercise of electrophysiology. There is no such thing as an electrophysiology society due to the small number we are, but we are together within the cardiology association within El Salvador. There is no training program for the training of cardiologists or electrophysiologists, so we have all been trained abroad. We have a team for the implementation of electrophysiological studies, diagnostics and conventional speech. We do not have a three-dimensional navigation system or intra-cardiac echo. The health system is distributed in three sectors. Within them we have the public system, social security and the private health system, which we will detail each of them. Within the private health system, 5% of the population is attended. We have those patients who have a private insurance, either with national or international coverage. The payment will depend on the copay that each of its policies contemplates. And we have these patients who cancel 100% of the consultation and procedures, who do not have any kind of private insurance. In this sector, most electrophysiological and speech studies are carried out, since they do have coverage. And of the devices, they also all have coverage. We implant step markers. We have carried out three hysian implants. They also include defibrillators and cardiac resynchronizers. Within the social security system, approximately 20% of the population is served. The payment that each of them makes is according to the quota that is monthly discounted from their salary and has coverage for medicines and some procedures. In social security, electrophysiological studies and discussions were carried out for several years, but at this time they are not being carried out due to damage to the equipment. Inside the devices are implanted mainly step markers and very few defibrillators. This is the sector that is working on a project for the acquisition of a three-dimensional navigator. In the public system, the largest percentage of the population is served. However, there is no coverage for the implementation of electrophysiological studies and inside the devices, only step markers can be implanted. Thank you very much. I would like to thank the Latin American Summit 2023 of the Cardiac Rhythm for the opportunity. Now we are going to present the topic B1 related to health problems and health policies. To be approved in our work as electrophysiologists, at least one of the specialists in the centers that exist in our country has been trained abroad. One of them in Buenos Aires and another in Madrid, Spain. From a theoretical and practical point of view, we have received support from Dr. Luis Barja, who has received the sponsorship from Abbott and Biotronic, and has come to our country since 2015, for 15 days, twice a year, to Havana and the city of Santa Clara to train the groups of electrophysiologists in these two provinces. We have also received support from doctors from Brazil, the United States, as well as technicians from El Ensaite, from Colombia. The qualification of the rest of the professionals is from courses of diplomas approved by the corresponding universities of Havana and Villa Clara, a course that lasts a year and graduates with a diploma certification. There are no university degrees in our country. Once these diplomats have graduated, they continue their work in centers where there are also professors who already have experience in the implantation of step marks or electrophysiology in the other centers of our territory. As for the implantation of heart devices, the devices are implanted in 13 provinces of the national territory, and in three of them, marked in red, which is the province of Havana, Villa Clara and Holguin, heart defibrillators and resynchronizers are also implanted, where qualified staff exists for this task. In the 13 provinces of the country that have implantation centers, there are a total of 19 implantation centers, 5 in Havana, 2 in Villa Clara and 2 in the province of Seville. The rest of the provinces have a per capita center. Here I show you a work that we have published in the year 2008 in the magazine Archivos de Cardiología de México, where it is shown that we have been working on stimulation in alternative sites, such as the septal region, to avoid cardiac dyssynchrony. In our country, we have developed this technique without counting on the use of a heart implant. We have two electrophysiology centers in Cuba, one in the Institute of Cardiology in Havana and one in the Ernesto Guevara Cardiocenter in the province of Santa Clara. In the Institute of Cardiology in Cuba, we have two electrophysiology centers, one in the Institute of Cardiology in Havana and one in the Institute of Cardiology in Seville. In the Institute of Cardiology in Havana, we have an Enzyme Velocity and a Radiofrequency Cubic. These are the arrhythmias to which we give the ablative treatment, but we must mention that at the moment the Enzyme Velocity is not working for the reasons that we show here and the Radiofrequency Cubic is working. We do not have intracardiac echocardiography in the country. In the Cardiocenter of Villa Clara, we also have a Radiofrequency Cubic and this type of arrhythmias is being worked on and performed. Observe here the ventricular arrhythmias with the Radiofrequency Cubic in the city of Villa Clara. Observe here the ventricular arrhythmias with the Radiofrequency Cubic in the city of Villa Clara. Here, an ablation in the region of the posterior ring of a ventricular tachycardia. Here, in the region of the tip of the right ventricle. And finally, this one that we show here, the ablation of a fascicular idiopathic ventricular tachycardia posterior to the left ventricle. The Cuban Society of Cardiology organizes scientific activities in the Institute of Cardiology generally once a year and also in the Cardiology Congresses that are organized by two of them in the country. One of national character and the other of international character, which increases the knowledge of electrophysiology in the cardiology and electrophysiology specialists of our country. And here I show you a panoramic view of the beach of Varadero in Matanzas. Thank you very much. We can start in Spanish, if you want, so that more people can participate. Well, we see a disparity in health systems in the different countries. There are places where most of the health is done in a private way, paying in cash. We see this reality in countries like Bolivia. We see others where there is also a very large disparity in health systems. And it is very difficult, sometimes, for people from the United States, from HRS, to understand us. So, I don't know, people from Brazil, what do you think? Mexico, what do you think? How can we, as LARS, help with this? I don't think so, but what do you think? Well, I will speak in Portuguese, so that you can understand me. I think it is a very complex problem. We have a common denominator in all of Latin America, which is, everyone talks about problems with infrastructure, training, equipment, industry, costs. We all have the same problems in different intensities. And I was here listening to the lectures and thinking, it is as if it were a critically ill patient. They don't have just one problem, they have multiple problems, failure of multiple organs, and they need an integrated approach. It is no use saying that we are going to put in Cuba more than 200 electrophysiologists, which will not solve the problem. We have to have an integrated government that listens to the doctors, the specialists who want to invest in health. They are broken governments, all with financial problems. So, I don't have the solution to all the problems, but I think the message that remains for me, listening to everything I heard today, is that we need to have an integrated action. And LARS can be this link for integration between several countries, that we can pressure government actions with the support of HRS, with the support of scientists, so that we can pressure governments and also pressure the help of the industry, which can also help us to gradually try to improve our numbers, which are really very, very low compared to the rest of the world. Yes, I would like to comment that we all know that our governments are not the ideal, it is a necessary evil that we have, but finally we need them. At some point we have to interact with governments and we have no choice. Some worse, some better in Latin America, but there it is. Here the question for Ana, for José, for Marcio, for all of you, is to try, and that is the objective of this, to try to see how we can help, how we can organize ourselves through society, through LARS, with the help of HRS, as you see, now we are trying to join efforts in many things. So the question is, how do you see, what do you think we need and what can we do as a medical society that we are, to be able to develop and advance a little faster in the development of our activity throughout Latin America? Well, I think it is indeed a serious problem that all countries in Latin America suffer from, the inequality in how resources are distributed, I mean, to a greater or lesser extent, we all suffer from this problem, and like many things in Latin America, we are used to doing the best we can with what we have and optimizing resources according to the realities we have. And in this sense, well, in Mexico it is very common, for example, that we reuse materials, catheters, devices have also been reused, donated, of people who pass away, and here we have scientific evidence that this is a practice that is ultimately not harmful to our patients, and I think that through LARS and our societies, what we can do is give this endorsement, this scientific support to these practices, which, well, are not entirely orthodox, but which do not harm our population either, and that, in a certain way, we are a little forced to carry them out to be able to benefit our patients. So, well, in the same sense that we mentioned a while ago of registration, census, I think it is also important to publish these experiences, which will probably spread to several countries in Latin America. I also think, as I mentioned before, that the issue is that I think that we as a society have to listen to people, listen, because I saw that there is, as you mentioned, that in different countries there are different realities. So, I think that, for example, in countries… I want to take advantage of the opportunity that HRS is giving us with this summit. For example, in countries that have difficulty training electrophysiologists, well, we could be a bridge for that. I think that HRS, that is an important thing for HRS. I don't know how HRS can take advantage of some of its strength to incorporate technology. I have no idea how it can be done. But, yes, to be a bridge for training, for people, that's for sure. That could be done with the help of society. Society should also listen to its partners. I think that we should always be open, or always ask how we are doing now. What are the needs? And maybe help someone who needs it with someone who can give. For example, with training. But I also think that it is very important to register, to have statistics of procedures, of centers, of devices, because that is very important. I think that maybe with the help of HRS and with the support of the industry, because that has a cost. I know that it can be done in other ways, but anyway, that has a cost. So, I think that is also very important as a plan for the future. Here in the panel is José Moltedo, who is a privilege for us in Argentina to have a pediatric electrophysiologist trained abroad. And I think that such an important sector of young people does not have the backup, the support of electrophysiology that Latin America should have. I don't know, José, what you could say. Thank you for the young man thing. I'm not that much. No, actually, I, listening to the problem that we have in the region, I would like to make a self-critical statement, if you want, of the LARS society. I think that we should all, as a community, look for a more effective way to get there. I think there is a bit of disconnection between what society does and reality in the different countries. And I think it is related to problems in internal communication and how we communicate. At the end of the first session, I heard about the need to make a diagnosis of the situation or the status of electrophysiology in Latin America to be able to know the nature of the problem and, from there, articulate potential plans to solve the problem. And, well, we, from the Pediatric Committee, two years ago we published in scientific journals the current state of pediatric electrophysiology. And I don't know if that was communicated in the way it should have been communicated and if it was given the value it should have been given. And I belong to the society, I am in the Electrophysiology Committee, and I feel that sometimes the arrival is not the most effective. This type of event may be useful, but it is also true that we are few, or relatively few, Latin American doctors who come. So, it seems to me that, from the LARS, we should ask ourselves how we can arrive better, communicate better, open up more the functioning and the decisions that are taken to be able to address the problem in a more efficient way. Any questions from the public? A comment? Alejandro? Well, we already know everyone's problem. We saw that everyone has a different problem. How do we react? Why react? If we stay with this, they will follow us. We are dead. So, this is a political problem, too. Health policy. So, we have to attack from that side, too. If we don't have a meeting, there was an Argentinean politician who said, if you don't want to work, make a committee. Right? Well, this is something similar. So, let's plan from now on what actions we are going to take to change this problem. To help those who don't have... For example, if I send a doctor to train in the best center in the United States and he comes and he doesn't have a card, he doesn't have anything, that's the last button. So, we have to solve the health problem that is a purely political problem. Problematic or a purely political health problem. We have to attack from that side, too. Not only... This meeting seemed barbaric to me, but if we stay here, I'm sorry to tell you that, as he said, self-criticism is a meeting, and we stay here. That's all. Thank you, Alejandro. Anyone else? Yes. Yes, I think it's important to establish a strategy. First, to make a photograph of the current situation of electrophysiology in Latin America, a diagnosis, as many have already said, and to make an action plan. And I have a proposal. LARS is going to be in Mexico, in just five months. We are not going to pretend that we have a solution to the problem, but we are going to create, in each country, a group that can be the same people who have been here, work, involve the other electrophysiologists from their respective countries, to know where we are standing. Because there is a very important heterogeneity, which is something that we have seen here today, and each country has a very particular situation, and I think we should start there, doing that, and have a preliminary, for LARS in Mexico, of the information that can be collected in each country, so that from then on, we can do an activity. Because, as the doctor said, it is a very true example. You can go to the best training site in the United States and Europe, and when you get to your country, you have the same deficiencies, the same problems, well, the truth is that we are not going to do anything. I think that is very important, to have a project, to analyze it in a first stage, and to be able to carry it out soon. And Mexico can be an excellent opportunity for a first launch on the day of what is being done in each country. Please. A short comment on a topic that has been touched on several times, and it is to get professionals to train outside, and the question that many did is, many of them do not come back, I am from Colombia, at that time I was training in electrophysiology in Canada, and it is the question that everyone asks one, and the truth is, I do not know, but the reflection is, what makes those people not come back, that is, why are not they coming back, and I think that much of what has been said here answers that question. So, what can we do, and let's say that from my personal position, or as an age group, so to speak, is, what can be done from societies so that those people go out to train and come back, that is, what can Latin America and societies offer from that point of view. Please. Well, listening to this session, it occurred to me that the sad diagnosis that we have in Latin America, the diagnosis is clear, but what can LARS do to perhaps drive some change, right? It occurs to me that the presence in the social networks of LARS would be fundamental and focus on countries with more problems. To hire expert people in the networks, to try to reach the health authorities through them, to seek that the population and the authorities understand the benefits in terms of mortality reduction, improvement of quality of life with the therapeutic procedures that the members of LARS can offer in each country. That is, to raise awareness in the networks, well managed. The industry would finance that perfectly. They are the most interested in increasing the number of procedures or the number of devices. It occurs to me that it could be a principle where LARS could focus on the therapeutic part of this problem that we are seeing today. Thank you very much. Well, we were talking in the short coffee breaks with Mauricio Escanavaca, with all our friends from Brazil and Argentina. One thing that HRES can start doing is making it easy for Latinos. Making it easy for Latinos, giving them facilities. We quickly started calculating the cost of coming to this congress and for Argentines, and they already said it before, it is almost impossible. So, to see how from LARS you can, as an organism that condenses that part, that concentrates, HRES out there thinking about giving grants for virtual access to the congress. Because it is no secret that in Latin America there are plenty of trained people, there are plenty of brains, there is a lot of potential. But if we do not promote that potential, we do not give it a little push, it does not go forward. It is also known that every time we leave this congress, all of us who come, we leave with that emotion of wanting to do a lot of things, because we start seeing things. Here we see, here is the world's evidence. So, the one who does not see it, does not have that impulse. That is why it is so important. I wonder, in a measure that HRES could take now, it is good, give away so many grants for virtual access. What would they do, for example, in Argentina? They would get together in a hospital room, of the hospital, to see all the congress. With a single grant, they would all get together, they would have sessions and they would get together. And in that way, we also progress in what is training, in what is the desire to do things. And the rest, they have already said, the political part of health and all that, I think it has to do more with communication, which is very difficult for us. Where I live, particularly in the Dominican Republic, communication is zero. And if we do not have communication, we do not have statistics, which to pressure and generate health policies, we need statistics. As long as we do not have our own statistics, we will not be able to achieve it. What happens if we cannot achieve it at the local level? We can have LARS statistics, and those LARS statistics have value in Latin America. So, that was a contribution for Echeres. What do you say? Thank you. Yes, really, I mean, here I have pointed out three or four very, very interesting ideas, but surely there are many more. So, in LARS, as José said, it has been quite difficult to communicate, because we are also a very large region. From Mexico to Argentina, it is many kilometers. And each country has its different idiosyncrasies and has its different things. But the idea of ​​this, along with the authorities of Echeres, is to try to have an approach. That is why at the beginning I said, it is exciting to have electrophysiologists from many countries, to have the support of the authorities of Echeres, and also to have people from the industry. Let's not forget that they can be a very important ally, but obviously they have to see the way to have a business, to have a profit, like everyone else. So, that union with the industry is very important. I would tell you, ideas, I think we have many. There is an email, the social networks, I think they are now being managed better. This idea of ​​social networks, in particular, I liked it a lot. And we have an institutional email, secretariat.lars, where you can write and be sure that you will always be answered. We now have people dedicated to this, who pass the news to us. We always try to improve communication, it is very difficult. Even when we meet with the Argentines, the Argentine jokes are very different from the Mexicans, and then we don't even understand each other. But hey, we are trying, and this is not a short-term project, it is a medium-term project. Here are the next people, the president, who will be the next in LARS. And as we speak with Luis, the relationship with Echeres is going to be closer every day. It has to be closer. They also obviously have an interest in what we develop, because that way they also develop things. So it is very important for us. I don't know if there is any comment. Luis, taking advantage of what you just said, I am curious if there is anyone from the companies who would like to comment on what we can do. Let's see if… We can see people over there. Yes, talking about social media. We are very, how can I say, very committed. We are in Abbot's team, we have been here for two days discussing how to support Latin America more, how we can help more with training, how we can help more with our technologies, more accessible costs. We are discussing why it is important for everyone, for patients, for industry, for you. We are looking for it. But the discussion that LARS can help us, how we can grow with our reimbursement, how doctors can help each other, be together and talk to HMOs to say, I am not going to work, I am not going to do a procedure that is going to pay me just this, and work for a reimbursement. Another thing that is very complicated for us in the industry, the whole IP business is a very expensive business, expensive with equipment, expensive with all kinds of systems, and reuse, reprocessing is a very complicated issue for us. Thank you, Vanessa. I think the people from Boston and Microport are not here, right? No. They left, right? You are from… Ah, yes, from Boston. Do you want to say something? Laura. How are you? I am Laura from Biosys. Nice to meet you. I think we have been working on pillars that I think we have common goals. First, training you and the new generations. Access, as you said, I think if we help patients arrive on time and arrive in a more agile way, we are going to win everyone, right? Because we are going to be able to give them better treatment. And the other thing is how we can also give continuity. There we can work together on data, right? On data that helps us have better conversations with data, with evidence for the government, right? So, I think if we work together, we are going to be stronger, but let's see how maybe in the transitions, right? Maybe of presidency, how can we give that continuity, because this is not resolved in a year or two years, right? So, I think that would be an important pillar. Thank you. I think that to talk to the government, we need data. So, the first thing is to create a record, the data. Because we know that if you put the defibrillator step mark with cardiac resynchronization, you have a reduction in mortality. In this morning's slide, I see that 70% of cardiovascular mortality in Latin America. So, we can increase or reduce mortality. Fibrillation is the same. We have data in the world that is an arrhythmia that has a progression, from paroxysmal to persistent. So, the early ablation will stop the progression. We need to show the data. Without data, the government is not going to do anything. We need data. Probably, if Colombia is separated from Argentina, we don't have enough data. If we put all the data together, it is probably stronger. It is a historical problem of Latin America, of Bolivar, that has to be all together to be able to emigrate. Probably for the industry as well. Because in the richest country like Brazil, richer, that has a larger number of procedures, has a larger volume of procedures, it is not necessary. But Venezuela, Peru, and Chile can do it. On Monday, there is coverage for ablation. On Tuesday and Wednesday, there is no coverage for ablation. It is impossible for a mapper to be in Peru all week without a case. That is not possible. But Latin America has coverage. It could be that on Monday is Venezuela and on Tuesday is Cuba. It is the procedure of the day. So, the mapper can have the day. It is an idea that I have now. But with volume, the cost is lowered and the coverage is better. We need that. If you allow me. I am John Salazar from Medtronic. I am a Colombian who has lived in the United States for almost 40 years. The difference between the United States and Latin America is not size. When you add up the size of Latin American countries, when you add up territory and even resources, the difference is the lack of unity. And you just said it better than anyone else would have said. You have the power of the world, but to use it, you have to unite and not think of yourself, but think of all those Latin American patients who are not receiving the services that you know should serve. As a union, as a union, create articles, things that let them know to all Latin American governments, I do not know where the differences are. And I think what Latino Latino has, he does not want to be the least, he wants to be the best, he always wants to be the best. He has that, he has that desire to be the best. But to be the best, you have to unify, and that everyone is the best, and that Latin America grows. I think I heard Abel, I heard Boston Scientific, I say it as Medtronic. We want patients to be treated, we want them to have access, but we require the commitment of the unification that you have, and the power you have, please. Thank you. Thank you. Well, finally, I would like to give the floor to Néstor, Néstor López Cabanillas. He is currently the secretary of our society. He is one of the main organizers of this event. Again, thank you very much for your participation, for your enthusiasm in this. I think it turned out pretty well. At least I liked it. Well, he will give us some final comments on what is the vision we have in LARD, of the future, of where we are going in our society. We, along with our sister societies, friends. Well, Néstor, go ahead. Thank you. Well, first of all, I want to thank HRS on behalf of LARD, and especially its president, Andrew Cran, Timothy Gregory, Patricia Blake, Luigi, who is next to me, Eduardo, and Michelle Anderson. Thank you, Michelle, for all your support. The HRS secretary gave us and helped us a lot. So I want to thank you for all the help you provided for this event and the excellent willingness to work together in many other activities. I want to thank all the delegates from Latin America who made a huge effort to condense in five minutes very difficult information to obtain, and allowed us to appreciate the very different realities of our countries. I also want to thank the entire LARS Directive Commission and the ex-presidents, and also the presence of most of the directors of the industry related to Latin America, which shows their interest in understanding us and getting even closer. Six years have passed since the foundational assembly of our LARS society, held on May 10, 2017, during a HRS congress in Chicago. Today we are already a well-established and well-positioned society worldwide, with our sisters HRS, IRA and Asian Pacific. But to continue growing, we needed to get to know ourselves even more. And it is only at this event that we show and discuss, as never before, the raw reality of Latin American electrophysiology, in what makes it one of the most frequent and difficult to manage. Two, the types of health systems. Three, the realities of electrophysiology as a human resource in terms of its number, possibility of training in your country, teaching and working correctly. Analyzing these three pillars, we have to better imagine the future of our specialty and create a program to achieve it. As for the first point, the pillar of diseases, the most frequent is auricular fibrillation, which cannot be treated in many countries due to the existence or low number of three-dimensional navigators, the lack of trained electrophysiologists, or the loss of training of those well-trained, as we just talked about, abroad, who, upon returning to their countries, cannot work. It is necessary for local scientific societies to raise awareness of doctors, patients, of the importance of proper management of auricular fibrillation, and that companies are encouraged to bring their technology to new markets. For our part, as LARS, we can take care of training courses that can go from the initial step, as Luigi said, of the transeptal function, courses on how to perform a transeptal function in different countries, to the workflow of auricular fibrillation. We cannot forget about the disease, as ours, as Chagas disease, and so related to political, social, and educational problems that limit the resources of the health system due to the need for step markers, defibrillators, complex ablations, and high-cost medication for the management of heart failure. We must find a way to help control it. As for point 2, the health system, there is a huge atomization of it in Latin America, going from countries where almost everything is paid with cash, to others with very complex systems. But an objective fact is that in many countries, high-cost practices such as implantation of defibrillators, resynchronizers, subcutaneous defibrillators, step markers, left ear closure, or ablations with three-dimensional mapping are not covered. The solution is complex and depends a lot on the economic situation of the countries and the awareness of governments and insurers. As for point 3, to conclude, the reality of the electrophysiologist, of the Latin American medical electrophysiologist, we saw that in several countries there is no arrhythmia society or an entity dependent on the local cardiology society, its creation being important to be able to share knowledge and develop local conferences with the active participation of members of the Latin American society. In many countries there are no local training courses or fellows programs, so it is vital that our society transcends borders and continues to grant training scholarships in North America, as has been done for a long time in Canada, and extends to Europe. We continue with webinars, courses at a distance, such as the Master of Cardiac Rhythm, or local theoretical-practical courses, which go from the advanced course of resynchronization implants that we develop in almost all of Latin America, through physiological stimulation, and reaching more complex techniques, such as the epicardial ablation technique. It is important the help of the industry and the availability of simulators. The absence of regulation for electrophysiology is a reality that must be solved and will allow to create a Latin American certification exam with real validity. To conclude, I want to emphasize that the economic problems of our region never managed to stop the logarithmic growth of our specialty. That is why the industry must continue to trust. But what can stop us is our own passivity and disunion, as we were just talking about. We must grow together, share our knowledge, because, as the great Master of Mexican Cardiology, Dr. Ignacio Chavez, said, they teach as much as they know, the risk of rotting with it. Thank you very much for participating and thank you HRS for being part of this. We need the support of the industry, but there is something that HRS can do with the support of the industry dedicated to you. We have a list of things that I was thinking about, from participation to the conference. The registration is very high for Latin America, but maybe we can find a way, a plan with the industry support from the transept courses to other things. Of course, HRS wants to collaborate and we are here and we want, but there is also an interest from HRS to have more members, more people as a member of both societies. We need to find the best way that we can support so that you feel, I want to be part of HRS in addition to LHRS, because I am receiving this from the mother society. We need to figure out at least two or three things that are key to start this collaboration. Of course, we can speak, but at the end we need to go to something that is practical. I am a member of the LHRS, I am a member of HRS and because of that, I get training, I get something that is practical, that can be touched. This is an important point that we need to achieve. This was very useful to understand what is the problem. There are more similarities than differences, as we said today. Anyway, thank you so much and on behalf of HRS, I would like to thank Michelle and Tim for supporting us. Marcio, myself and Nestor that have been in all the meetings together with Eduardo as part of the Global Relations Committee and the current president, Ulysses and all of you that are in person or connected via Zoom for being part of this summit that was very well attended and supported. To all the industry people that were here to hear and to understand what can we do to improve the patient care, which is what we want. We want to treat more patients and to save more lives. Thank you very much to all for being here.

Latin American Summit 2023

Electrophysiology experts

Collaboration

Information sharing

Arrhythmias prevalence

Resources availability

Training programs

Healthcare policies

Atrial fibrillation

Limited resources

Funding variations

Technology use

Collaboration importance

Education advocacy

Policy advocacy