So, hello, everybody who is out there in the virtual world and here in person. My name is Fred Kusumoto. I'm the current president of the Heart, Limb, and Society for another couple of days and Andrew Kron is going to be taking over for me come Sunday. But at least during this period of time, this is something that Dr. Shimizu and I have been working on for the past year to really bring together APHRS and HRS for this Asia-Olympian Summit. So, with me is Wataru Shimizu, who is from Japan, who is the current president of the Asia-Pacific Heart, Limb, and Society. And on behalf of Asia-Pacific Heart, Limb, and Society and us, Heart, Limb, and Society, we wanted to convene a summit that would really focus on the Olympian management of patients in Asia, because we all recognize that care around the world is different and that response to therapies is different. And in fact, within your region, which is so diverse, that the response in Thailand or a patient's response in Thailand might be very different than that in Japan. And that the health policy issues that faces a healthcare provider in, let's say, Singapore is very, very different than something that is faced by someone in Sri Lanka. So again, even as I mentioned those names of those countries, we all realize the heterogeneity of your region. And so, what we are going to do in this first Asia Summit, we would like to first focus on clinical issues. And so, each of the countries has put together prerecorded discussions about some of the specific clinical issues that face their individual countries. We're then going to follow that with a panel discussion, where we will then be live and be able to then talk about these issues amongst us all. And I think with that, trying to identify maybe some best practices, et cetera, we'll have then a short break. And then we all know that patient care, real delivery of patient care required more than just the patient. It's really the delivery of care. And each of us faces different health policy issues in each of our countries that are unique. But there might be some similarities, and I'm very intrigued by whether or not with this discussion, we can identify again, best solutions, how to manage some of the barriers that we all face. So I am all very excited about this. And for those of you who are online virtually, just know that I want deliverables out of this. And the deliverables will be, obviously, that this summit will be recorded and be on HRS 365 and the APHRS site, so that people can view that. And in addition, we are going to put together an actual manuscript that really highlights some of the issues that face both of our sort of areas and your entirely diverse region. So Mataru, are you on yet? I want to give you the final word before we go on to the recorded sessions. Thank you. Now I can hear your voice very clearly and without noise. So it is my great pleasure and honor to be your co-chair with Professor Fred Kusumoto. And we will have our Asian Summit 2022. So I'm very pleased to hear each presentation. Thank you. Excellent, Mataru. So again, we are all excited about this, and we'll go ahead and start the presentations thinking about the political issues that each of our countries face. So go ahead and start rolling the video. Dear Chairman, ladies and gentlemen, this is Dr. Minglong Chen from Nanjing, China, on behalf of Chinese Society of Basic and Electrophysiology. Here are the major clinical reasoning problems in China, ranking number one is sudden cardiac death. Number two is atrial fibrillation. The last two, bradycardia and SVT ablation, only needs the promotion to rural areas and those lower tertiary hospitals because these two techniques are widely accepted procedures. Here's the total number of pacemaker implantation and the total number of test ablation procedures. Back to number one issue of sudden cardiac death, it was estimated that 540,000 deaths each year in China, but this was certainly underestimated. The public campaigns against sudden cardiac death and the screening high-risk patients to implant ICDs and also promote AED in public places and also the CPR in all the public places are the important steps to reduce sudden cardiac deaths. When ICD implantation is mentioned, you can see that ICD therapy was insufficient in China. Only around 5,000 implantations occur each year in China. This is chiefly because of poor recommendation, the economic and the cultural background. Therefore, educating the patients, the guideline-directed medical therapy promotion, and also improve the reimbursement policy should be conducted. So number two is the atrial fibrillation. You can see that the prevalence of AF in China is 1.6% with the total number of AF patients approximated 20 million and 50% of all these AF patients are in the rural areas. Public campaigns organized by government, by big hospitals, by professional societies to do the public campaign against AF and the stroke. Because of this work, you can see that OAC prescription rate is increasing and also with new reimbursement policy, the DOAC was prescribed increasingly. And also the AF ablation procedure, you can see that the annual case number and it was estimated that 80,000 cases of AF ablation was performed last year. For AF screening and AF management models here are the example works done in China. MAFA program focused on the high intellectual population AF screening and management. This program is focused on those patients live on the suburbs. And also this program is focused on the patients living in the communities of big cities. Our program is focused on the rural elderly patients with AF because this unique population was described as these five lows. Because of these five lows, all these pathways to improve AF management are less reliable. And the only pathway is to empower the village doctor with the ability to manage AF patients in rural areas. We should build a platform through online medicine. And this is the virtual scene of this program. So each village doctor is in charge of five to 10 patients of AF, but the AF specialists are behind online. And the chronic issues we are facing in China, finally, the coronary artery disease, the chest pain center has been well conducted and TCI has been well disseminated and popularized. However, the cardiovascular risk factor control for prevention of coronary artery disease is critical. Heart failure, optimized drug therapy and device therapy are wheeled on in the big tertiary hospitals, but the guideline-directed medical therapy must be promoted and generalized in lower tertiary hospitals. Vaginal heart disease, the number of patients with rheumatic vaginal heart disease is decreasing while degenerative vaginal heart disease is increasing. Preventive measures and effective management are lacking. Arrhythmia disorders, catheter ablation is a well-established treatment, comprehensive treatment for high-risk patients to prevent arrhythmia disorders is important. The vascular disease is very much similar to the coronary artery disease. Thank you very much. Hi, I'm John Kelman and on behalf of my colleagues listed, it's a pleasure to present on the area of clinical challenges in arrhythmia management in Australia and New Zealand. Well, we know from data that there is a very high incidence of atrial fibrillation reported in community-based studies in Australia and around the region, but we can see that this is the prevalence is particularly high in Australia at around 4% compared with other countries in the region. Now, not surprisingly, we see over the past 15 years or so that the rate of hospitalizations for different cardiovascular conditions has seen atrial fibrillation increased to the rate that it really is, has comparable admission rates to both coronary disease, myocardial infarction and congestive heart failure. And consonant with this increase in atrial fibrillation is an increment in the number of AF ablations performed over the past decade with a 23% annual increment, quite striking, all ablations increasing and at a much higher rate than overall PCIs. But what we do see with AF ablation is also what's seen around the world, which is a very wide variation in the range of hospital complication rates from those in green, which are below the average to those in red, which are above the average. And when we look at that by hospital volume, we see that most of the high rate of complications are doing less than 100 annual ablation volume and that those doing high volume tend to fall below the average complication line. We can also see that the vast majority of ablation centers are doing less than 100 ablations a year. And this is consistent with data now from around the world. Meta-analysis showing that institutional volume less than 50 or less than 100 is associated with significantly higher complication rates. Now another problem unique to the region is the high incidence of comorbidities in the indigenous population, whether they don't or do have atrial fibrillation. Almost all of these comorbid conditions are significantly higher in the indigenous population. And this translates into the CHADS-VASc score. In the light blue, the indigenous population is underrepresented for low CHADS-VASc scores and overrepresented for high CHADS-VASc scores 2 and above. We also see that in any given age range, both for men and women, the incidence of atrial fibrillation is higher in the indigenous population than in the non-indigenous population. Now access to weight loss clinics around the country is an issue in AF management. We know very well from the work of Prashanda's group in Adelaide, the weight loss is one of the centerpieces of management of atrial fibrillation. And we see that patients who maintain over 10% weight loss almost exclusively have done this by attending clinics, whereas those who are unable to maintain weight loss, less than 3%, a much lower percentage can attend clinics and indeed around the country, access to this type of specialist clinic remains extremely problematic. If we think of ventricular tachyarrhythmias, we see the same sorts of trends. Look here in the light green, VT ablations over the period of a decade, incrementing by 18% per year over this timeframe, AF ablations also incrementing significantly. You can see that all cardiovascular procedures up here are relatively static. So most of the increment is in catheter ablation, particularly in VT and AF ablation. But there are significant challenges still in the area of ventricular arrhythmia ablation patients and not frequently referred for ablation. It's viewed as a treatment of last resort, there's under-treatment of ventricular tachyarrhythmia storm and many patients have overuse of antiarrhythmic drugs and in particular amiodarone. As with AF, there's a marked heterogeneity of volume of arrhythmia ventricular ablation procedures performed at different institutions and lack of minimum standards for operator and procedure volume. But we know from the work of Sarab Kumar's work in Australia that in patients undergoing ablation for structural heart disease related VT is a very high ability to achieve significant reduction in ventricular arrhythmia burden, 83% of patients achieving greater than 75% arrhythmia reduction. Now, as with VT and AF, we see for implanted devices, significant increments over the past decade that is present both in men and in women. So around the region of Australia and New Zealand, in conclusion, we see an increment in the full spectrum of arrhythmia procedures and this is creating a range of unique challenges. Thank you very much. Ladies and gentlemen, it's my greatest honor to take part in this summit. My task of the day is to discuss the clinical issues in Taiwan focused on the epidemiology of arrhythmias and the specific risk factors. Taiwan, the population is about 23 million and we have about 500 hospitals and about 51,000 physicians, including 220 EP doctors. More importantly, we have a very powerful research database called the National Health Insurance Research Database, NHI. So this system, including the data, information from the health care provider, the hospital and the patient's diagnosis, its coverage rate is about 99% residents in Taiwan. Based on this data, big data, our experts can identify the risk factors. Estimate the epidemiology of atrial fibrillation. In terms of projective AF prevalence, you can see the AF prevalence is about 1.5 in 2020 and 1.8 in 2025. We also can report the incidence rate of different age strata, as shown in this slide. The AF incidence increased with the age. The prevalence rate is also in a different age, can be demonstrated in this slide. And the male and the female patient, they have the similar prevalence. In the real world, we also conducted the ELAN study in the suburban area. This is a population-based cross-sectional community survey, which included 3,500 residents with the age of more than 65. We performed the ECG and the heart rate variability screen in this resident. And we found the AF prevalence rate of age more than 65 years old is about 6.5%. This data shows the incidence of the different age range. In addition, the male has a little bit higher prevalence than the female. My colleague also developed a Taiwan AF score to predict the incidence of AF based on this database. The advantage of this score is we can only use the clinical variable, no need of lab data or echo data. No need of lab data or echo data. We can predict the AF incidence here, including using the age, the hypertension, heart failure, coronary artery, and ESRD alcoholism. And we can divide the patient into three groups with different risk. And the cumulative risk of AF occurrence can be calculated in this table. In addition, we also found the sudden cardiac death in AF patient is higher than the non-AF patient. This slide shows the annual risk of sudden death in AF patient is about 0.97%. And in the non-AF patient is 0.47%. In the real world, in central Taiwan, also a registry to find the sudden death rate in the central Taiwan, which covered the 2.7 million patients. And in this registry, you can find the overall incidence of OCA is about 74 per 100,000 person years. And specifically, if you look on the incidence of CVOCA is about 60 per 100,000 person year in our registry. In addition, most of our patients can have a response time less than six minutes. The most remarkable is in this registry, we can find the AED with shockable reason is only about 7.9%, which is a relative low compared with the Western country data. The subgroup analysis, you can see the male and the age less than 65 and the place of rest in public, which can predict the VT, VF occurrence in this patient. Lastly, I want to mention the PSVT related admission. You can see in Taiwan, the female is a little bit more than the male. We still have some patients who do not receive the radiofrequency abrasion, and mostly, they are aged people and the young people, most of the young people can accept the radiofrequency abrasion. Thank you for your attention. Hello, and good morning. Thank you for your attention. Hello and good morning. Thank you very much for the very kind invitation to speak today on the current status and issues regarding Arabia services in Gunai Darussalam. I'm the president of the Art Society and the APHS country representative. So, Gunai Darussalam is a small country on the coast of Borneo Island in Southeast Asia. It has a small population of around 420,000 people and tertiary psychotic services are provided by a hospital located on the northern coast of the country. They offer coronary artery bypass co-opting, valve surgery, PCI and EP services in the last 10 to 15 years. Looking at the country as a whole, there are basically six main hospitals and just over 1,000 beds, about 700 to 800 physicians, and we spend approximately 2.17% of our expenditure on health as a percentage of GDP. The country is funded, healthcare is funded by the government. Patients have to pay very little out of pocket, so healthcare is free at the point of delivery for the majority of people in Gunai. In terms of the leading cause of death, it's cancer, but of course, heart disease is the number two cause of death in Gunai Darussalam, very typical for most populations. There has been a demographic shift in the cause of death in keeping with a shift away from infectious diseases to respond to diseases, as we can see here, from 1967 to 2011. Unfortunately, Brunei is one of the most overweight or obese countries in South Asia. We can see here quite a high percentage of the patients are overweight or obese, defined as BMI of 25. So of course, this results in an increase in presence of diabetes and heart disease. So in terms of what's available in Brunei, we have electrophysiological studies and ablation, surgical ablation, SVT ablation, ablation for ventricular topics and ventricular tachycardia. Pacing services have been available for over 30 years, dual chamber, single chamber pacemakers, and more recently, we've started conduction system pacing and leadless pacing. ICDs and CRTDs are implanted routinely, and with that, we also perform lead extraction, and also, we also perform left ventricular appendicitis and also, we also perform left ventricular appendicitis infusion for patients who are at high risk of bleeding, and that's coagulation, and high risk of stroke. In terms of procedures, this is data from the last five years. You can see here that we generally have around 100 and 120 procedures a year, but the majority of them are atrial fibrillation ablation. Second most common is SVT ablation, third most common is ventricular topic ablation. So I think this is fairly typical of what we see in a lot of centers. The patients coming to for ablation generally have symptoms like palpitations and dyslip or heart failure symptoms. Less commonly, they have dizziness or chest pain. Comorbidities are fairly typical amongst this population. Hypertension being the most common probability, followed by heart failure, diabetes at 19%. The prevalence of diabetes in the population falls around 11 to 12%, and the prevalence of hypertension in the population falls around 25%. The CHAT score of patients coming for ablation is fairly low, 1.1. CHAT's best score is 1.7, so fairly well population. We did look at our results a few years ago for practice-monitoring system and long-standing dissonant atrial fibrillation of those patients, and this is data for first-time procedures. So you can see here that in general, our results for practice-monitoring fibrillation are around 85% or so for persistent, about 70% and for long-standing persistent, just under 50%, which is fairly typical of the results for the population as a whole. SVT ablation is data from last year. We tend to use 3D mapping for all our procedures, including SVT ablation, so the thorough time is on the low side, three minutes. Ventricular topical ablation, again, our third most common procedure. Currently, the thorough time is generally around three minutes, and most patients stayed for an average of two days, less than two days. We have implanted leadless platelets as well, and we were one of the first countries in Southeast Asia after Malaysia to implant a leadless pacemaker, and we did this in 2015, and we did publish our initial results for the first few cases and showed that the results have been satisfactory. With the current excitement for histoplasmic pacing and pediatric assisted pacing in general, we also started the service. This was a few years ago, and it was our first case, which we published in the APHRS newsletter some years ago, in a patient with impaired ejection fraction, post-coronary artery bypass grafting, and PCI, and impaired DF. He had a sinus rhythm with a long period of 278 milliseconds, and his scalp might benefit from a shorter AV delay. He had impaired LD function. The alternative was a CRT device, but we'd like to try histoplasmic pacing here, and you can see the final position of his lead here, and a nice non-selective histoplasmic capture with threshold of less than one volt at 0.4 milliseconds for this case. So what is the future for the RISC-B service in general? We hope to do more production system pacing, although, of course, the evidence base for this remains to be developed. We have also started doing left bundle branch area pacing with some promising results, and the thresholds are definitely better in our experience of histoplasmic pacing, as is seen in most of the centers. We have some issues with AF detection and screening in Brunei, so we hope to increase the uptake of AF screening. We have not mentioned here, our outcomes for CPR in Brunei could be improved when we looked at our in-hospital and out-of-hospital cardiovascular survival. The results were perhaps disappointing, and we hope to improve the training of bystanders and of healthcare providers. With that, thank you very much for the opportunity to share with the services of Brunei Darussalam, and I hope that this will provide some grounds for discussion. Thank you very much. Hello, everyone. My name is Sirin Appiyasawat. I'm representing the Thai Electrophysiology Club, and I'm here today to address our clinical issues regarding the heart rhythm disease. Overall major healthcare problems in Thailand, according to the report by Health Strategy Research Institution of Thailand, are health literacy of the citizen, which is number one. And number two is the aging population that are increasing the same as the rest of the world. And number three is rational drug use. Number one major cardiovascular problems in Thailand is coronary artery disease, followed by heart failure is number two, and arrhythmia is number three problems. And for the arrhythmia problems in Thailand, similar to the rest of the world, atrial fibrillation is number one. We have Brady and SVT number two and three, ischemic number four, and non-ischemic and Brugada VT is number five. AF is number one problem in our country, so we expect to see number of AF ablations increasing. As a matter of fact, number is up. Look at this data from the report of 2019 and 2020. Annual numbers of AF ablation per million population of Thailand is increasing over the year. However, the absolute number is relatively small. 2.5 per 1 million is extremely small compared to the rest of the world. What we think is the reason behind that is the number of operators and the number of centers that perform AF ablation. What we're seeing here is after we develop the standards for EP training, we certify the center that train the EP fellow and we certify the trainees as well. We have more centers that are able to perform AF ablation and we have more as a result of the new coming electrophysiologists that are more keen to ablate the atrial fibrillation. In the long run, we foresee that this problem would be gradually resolved since the development of the EP fellowship program. So, in summary, AF is the leading arrhythmia problem in Thailand. The current numbers of procedure are relatively small, but we expect them to be increasing after the establishment of formal fellowship training. Thank you very much. I'm Seil Oh, and I'm very glad to share Korean data with you. I will talk about clinical issue in South Korea. My topic is Epidemiology of AF and I will introduce nationwide population-based studies we have performed and prospective registry data of Korean atrhythm society. In Korea, along with the aging population, the prevalence of AF has been on the rise as a global trend. The prevalence of AF nearly doubled across an 80-year period, as you can see in this slide. Now, around 1% recently, and the increase in the number of AF patients recently, and the increase in prevalence was more pronounced in the elderly population. This slide shows projected prevalence rate and number of AF. Looking at the projected prevalence rate, the AF prevalence can be estimated at about 6% in 2060. As a risk factors for AF, genetic predisposition, aging, various underlying diseases, and lifestyle haven't been known. In addition, new risk factors suggested through recent epidemiological studies have been introduced. In the Korean population, age has the largest effect on raising the risk of AF, and male sex, obesity, hypertension, dyslipidemia, and myocardial infarction were significant risk factors of AF. Representative studies on AF risk factors that have been analyzed based on recent data from the Korean National Health Insurance Service Database are as follows. Hypertension, under and overweight, and accumulation of metabolic syndrome components reflecting insulin resistance are significantly associated with increased risk of AF. And total alcohol consumption and frequency of alcohol use frequency of alcohol consumption are both significantly related to the risk of AF. These are newly found risk factors. Proteinuria and body weight fluctuation are both independently related with an increased risk of AF. And inflammatory disease such as inflammatory bowel disease and atopic triad are associated with the risk of AF. Now, catheter tabulation. The numbers of patients underwent catheter tabulation for AF were observed to gradually increase over 11 years. About 500 patients in 2007 versus more than 3,000 patients in 2017. Korean Heart Rhythm Society developed prospective AF ablation registry enrolled more than 3,200 cases for two years. According to the registry data, pulmonary vein isolation was performed in 99% of patients and acute success rate was about 98%. Additional non-PVA ablation was performed in 69%. And one year AFI-free survival rate was about 79%. Post-procedural complication rate was 2.2%. Interestingly, additional non-PVA ablation was associated with better rhythm outcome in the patients with persistent AF, not in paroxysmal AF. Thank you for your attention. Kamsahamnida. It is my great pleasure to have a presentation on clinical issue in Japan, focusing on clinical diagnosis and risk stratification in Brugada syndrome. This is my disclosure. This slide illustrates cause and rate of sudden cardiac death. Inherited arrhythmias, such as Brugada syndrome, are one of the cause of sudden cardiac death and account for approximately 10% in Japan. Shore are underlying heart disease in ICD primary and secondary prevention in Japan. Inherited arrhythmias, including Brugada syndrome, account for 16%. Brugada syndrome account for 10% of primary prevention and 7% of secondary prevention. Brugada syndrome is common in Southeast Asia and some cases of Rai-tai in Thailand or Pocri in Japan are at least thought to be Brugada syndrome. The prevalence of type 1 Brugada CG is significantly higher in Japan and significantly higher in Asia, 0.15 to 0.27% compared to Europe or United States. According to previous report, the annual cardiac event rate in Brugada patient with a history of VF or aborted cardiac arrest was 7.7 to 10.6%, 0.6 to 1.9% in patient with syncope alone only 0.3 to 0.5% in asymptomatic Brugada patients. Shore are the predictors for lethal cardiac events in Brugada syndrome. A history of VF or aborted cardiac arrest is the strongest predictor for subsequent cardiac events, 10% of recurrence of VF. A history of syncope, spontaneous type 1 ECG and male gender are also reported to be a significant predictor. On the other hand, the induction of VF by EP study, family history of sudden cardiac deaths or SCL5A mutation have long been controversial as a predictor for cardiac events. Regarding the induction of VF by EPS, a systematic review and a pooled analysis of Brugada patients without a history of VF suggested the induction of VF with a single or double extra stimuli was associated with a higher risk of cardiac events, confirming the usefulness of EP study for risk stratification. More recently, Asian group conducted a systematic review and a meta-analysis regarding family history of sudden cardiac deaths and suggested a history of sudden cardiac deaths among family members of age younger than 40 years was associated with a higher risk of major arrhythmic events. We conducted the prospective Japanese Brugada Malach Center registry with SCL5A mutation data. Kaplan-Meier curve of overall survival is shown in this slide. The Brugada programs with SCL5A mutation had a higher cardiac event rate than those without SCL5A mutations. Especially the Brugada programs with SCL5A mutation in poor region showed the highest cardiac event rate. In multivariate analysis, only a history of aborted cardiac arrest or SCL5A mutation status persisted as significant predictors. Shown are the predictors for recent cardiac events in Brugada syndrome revised by recent data. In addition to a history of VF or aborted cardiac arrest, syncope, spontaneous type IECG, male, gender, induction of VF with up to two ventricular stimuli, primary history of sudden cardiac death, SCL5A mutation are now significant predictors as evidence level B or A. Shown are the ICD indication for Brugada patients in Japan according to the Japanese guideline. ICD should be considered for patient with type I ECG and unexplained syncope and with inducible VF with up to two ventricular extra stimuli. ICD may be considered for asymptomatic Brugada patients with spontaneous type 1 ECG pattern and considerable clinical or ECG findings, including primary history or HCL5A mutation and with inducible VF with up to two extra stability. This is my conclusion. Thank you for your attention. I am Nguyen Hue, country representative of APHRS. I'm going to present the clinical issues in management of cardiac arrhythmia in Myanmar. As a developing nation, Myanmar is dealing with various clinical problems in arrhythmia management. Rheumatoid fever and rheumatoid fibula heart disease are common in Myanmar. Eight cases of rheumatoid mitral fibula disease presenting with the atrial fibrillation is the most common. Atrial fibrillation with underlying fibula heart disease is ranking first in Myanmar for cardiac arrhythmia. Supraventricular tachycardia undergoing the RF ablation are most common cases in EP lab, followed by pacing therapy for bradyarrhythmia. Ventricular arrhythmia, either due to ischemic or non-ischemic in origin, and hereditary arrhythmia are less common. Although the epidemiologic data for various type of cardiac arrhythmia is not available in Myanmar, these are the ranking orders of the cardiac arrhythmia facing in the tertiary care center in Myanmar. In addition to the cardiac arrhythmia, coronary artery disease is the most common cardiac disease due to the increasing prevalence of cardiovascular risk factors like hypertension, diabetes mellitus, and dyslipidemia in accordance with the unhealthy lifestyle. Timely management of acute coronary syndrome with either thrombolysis or primary PCR plays a major cardiac issue. Heart failure due to either ischemic or non-ischemic cardiomyopathy and fibula heart disease contribute to the major healthcare burden because of the repeated admission and prolonged hospitality, utilizing a great proportion of the healthcare budget. Burden of congenital heart disease and vascular diseases are much less common in Myanmar. Regarding the management of the cardiac arrhythmia, access to the arrhythmia service is still limited for people living in the district and remote areas. Antiarrhythmic medications are available during hospital stay, but continuing treatment is at patient-owned expense. Sustainability of available treatment and monitoring of anticoagulation therapy cause a major healthcare burden in Myanmar. Simple interventional procedure like SVT ablation and single-chamber pacemaker implantation at public hospitals are cost-sharing method. Patients have to pay approximately 20% of the total expense. These are the interventional procedure in Myanmar from 2015 to 2020. We do have the increasing number of the interventional procedure like catheter ablation or arrhythmia and CIET implantation. However, in 2020, because of the COVID situation, there is a decreasing number in the interventional procedure. Regarding the HR training and workflows, physicians are trained according to structured training program for general cardiology. Look at basic hands-on training for arrhythmia services provided for EP fellows who can have further overseas training. There is a huge gap in the training program for EP technician. It needs to be expanded and upgraded. Thank you for your attention. Thank you for this kind invitation to Asia Summit 2022. I am Chi Keong Ching, and on behalf of Heart Rhythm Association of Singapore, I present the data from Singapore. These are my disclosures. Singapore is a small country. It is located one degree north of the equator. The east to west is about 40 kilometers, and the north to south borders is about 25 to 30 kilometers. Some of the demographics is as such. In the year 2021, we reported a population of 5.5 million. The median age is just under 42 years old, and about under 12% of this population are age 65 years and older. According to World Bank, the GDP per capita for the year 2020 is just under 60,000 USD. And these are the data for EP and pacing. It is collected from a national registry, and we contribute to the data published in the AP HRS White Book. This is the data at a glance. The population ranges from 5.6 to just about 5.7 million through these years. Pacemakers were implanted at a rate of 143 per million for the year 2017 to the high of 162 per million in the year 2019. CRT per million is about 30 to 36 per million through these years. The ICD per million too is about 70 per million through these years. You will see that the ablation per million, which is a high of just under 170 per million for the year 2018, it drops to about 130 per million for the year 2020 due to the impact of COVID-19 pandemic on largely elective ablation procedures. About 40 to 47% of ablation would comprise of AFib or atrial flutter ablation, and about 12 to 16% would be ventricular arrhythmias, be it PVCs, non-sustaining VTs or VT ablation. The rest would be SVT ablation. Now, despite having a high GDP per capita in a small city state with good infrastructure and access to complex or high-tech medical care and treatment, we do face challenges. One, the adoption of guidelines can be improved with respect to arrhythmia management and CID implantation. And I think work with societies such as heart rhythm societies and national cardiac societies, or family physician societies would help to educate referring physicians on the life-saving measures of such guidelines for patients with heart rhythm problem. There is an increased emphasis on value-driven care by the payers. So questions such as, will a leadless pacemaker deliver as much value as a transvenous single-chamber pacemaker? And the simple equation for value equals outcome divided by the cost. And there'll be other similar questions too, especially we rely on fairly high-tech, fairly costly equipment to deliver such care to our patients. The healthcare cost is rising in Singapore. There is increased chronic disease burden, and the population will age. It becomes potentially unsustainable. And hence, there is a shift towards a capitation model to fund the healthcare system in Singapore. And we know there are limitations to this capitation model. So there are challenges in Singapore, and we strive to work within these challenges to continue to deliver care to patients who would benefit from healthcare or heart rhythm management. With that, thank you for your attention. It's my great honor to represent Mongolia in HRS and APHRS Summit. And today, I am going to represent about the major obstacles of EPT in Mongolia. And I am Dr. Saruul Silente. Mongolia has a total population of 3.4 million. And in 2016, we started the EPT service in Mongolia and we started the EPT procedures and the catheter ablation treatment. In the last 20 years, the number one mortality cause in Mongolia is a cardiovascular disease followed by the cancer. And as in Mongolia, until the 2016, Mongolia, the doctors didn't use the ICT code for ischemia disease. We don't have any statistics data regarding of the ischemia heart disease. And even we don't have a sudden cardiac death record until the 2016. We are forcing to have an ischemia disease code and we are also forcing to use a sudden cardiac death term for Mongolian doctors. But the old habit changes slowly. And here is our last five years, last four years procedure numbers. We have had the start of the patient care implantation in 2015 and our patient care implantation case numbers is increasing slowly. But now in 2021, we did almost 250 implantation case. About the EPT procedures, we started in the 2016 and our cases gradually increases also. But in the 2020 and 2021, because of the COVID infection, our cases decreased. And ICT and CRT implantations, our cases is very small, less than 10. But we are planning to increase our ICT and CRT implantation cases in the near future. So, we have a major clinical arrhythmia problems in atrial fibrillation and all kinds of centrical arrhythmias, VT and PEC cases and pediatric arrhythmia cases. For atrial fibrillation and VT and pediatric arrhythmia patients, we offer oral medication or external cardiac dilutions and ICT implantations. Why we cannot offer more treatment for these cases, for these patients, is because mostly due to 3D mapping technician. In Mongolia, we don't have a 3D mapping technician. So, we cannot perform more complex arrhythmia ablation treatment. And next is connected to the inherited arrhythmia disease. Most of the inherited arrhythmias, we do not recognize and because we do not recognize them, we cannot treat them. So, but in the very rare cases, we found in Mongolia, the inherited arrhythmia disease and we implanted the ICT. So, most of the countries have its own problem when the initial part of the development of IT service. So, we also have our difficulties. First is our workforce. For 3 million patient, for 3 million population, we have only three independent ablators. But we are increasing our EP doctors and now three doctors are under the training. And we have 16 centers and we have one EP nurse and EP technician and we don't have a 3D mapping technician. It's whole country. So, why is this we cannot train our staff more? So, our biggest, second biggest problem is connected with the training. It's because we don't have many local companies and these companies do not cover training for them. We don't have a scholarship and also the Ministry of Health covers training only for doctors in a very short period from 14 days until the famous. So, there is a very difficult issue with the scholarships. And also, our doctors are having a problem with finding international scholarships. It's because of the most international scholarship is offering for the abstract and the submitted papers, but for Mongolian doctors, the submitted papers, EP papers is limited numbers. So, we cannot find the international scholarship because of the paper submission. So, our third biggest problem is facilities. We don't have EP-dedicated laboratories. Only the laboratory in Mongolia, which is working, is shared with the near international part and the contact international part. So, it's very difficult to find the working hours in this shared laboratory. That's why our numbers, the EP case numbers, do not increase. It's increasing very slow. So, with the help of the ministry and with the help of the first central hospital in Mongolia, we are now opening the second EP laboratory. But still, this EP laboratory is shared with the primary angiography part. And this is the whole situation in Mongolia. Thank you very much for your attention. Now comes the really fun part. We've had this incredible set of lectures delivered to us, which really shows some commonality, but also differences between the different countries. And now we get to have the panel discussion and really try to hash out some of these issues, focusing mainly on the clinical side of things. So, we are having a panel online, which is really exciting. I guess that's the one good thing that's come out of COVID, is you can learn about this sort of world, both in person and virtual. So, I'm going to let the panelist who are with me here first introduce themselves. So, Vicky, why don't we start with you? Okay, hello. Thank you, Fred. Yeah, I'm Vicky Hanafi. I'm the president of the Indonesian Heart Rhythm Society. And I was lucky enough to be in person here in San Francisco. Thank you for the invitation. I'm glad you're here. I'm Jenny Fairweather. I'm in Dallas, Texas. And I'm the president and abstract chair of this wonderful meeting. And I'm Andrew Kron. So, I'm the incoming president for HRS. I'm from Vancouver and feel a certain affinity to Asia because you're just across the water from us in Vancouver. So, it's great we could all be together and learn from each other. That is so true. We have a wonderful virtual audience. I'm going to ask each of them to introduce themselves. But I'm sure especially so, Minglong. Hello. Hi. Professor Kosmoda and Professor Shimizu. This is Dr. Minglong Chen from China. Currently, I'm the vice president of Chinese Society of Paging and Electrophysiology. And also, the APHR subcommittee chairman of International Relations Affairs. Thank you. Professor Oh. Yes. This is Sayo. I'm very glad to hear with you. And I'm a representative of Korean Heart Rhythm Society. And we will have a great time in this special seminar. Thank you. Wonderful. Professor Nguoi Nguoi. Hello. I'm Nguoi Nguoi from Myanmar. I'm still working in the Yangon General Hospital as a BP doctor. And I'm just a representative of the country representative of Myanmar. Thank you. And Professor Kohli. I know you don't have your camera on, but are you on? No. So, Tachapong, I see you there. So, do you want to introduce yourself? Hi. I'm Tachapong Namuthose. I'm from Bangkok, Thailand. Wait, I got my name on as Sirin. Sirin's supposed to be with me here somewhere in the building downstairs. So, I'm not real Sirin. Good to see everyone. Good morning. It's great to see you. Tachapong is the outgoing or was just the immediate past president for APHRS. Wataru, I'll let you go ahead and start the discussion. Okay. Thank you very much for introducing me. My name is Wataru Shimizu. I'm a current president of APHRS and the Japanese Autism Society. So, thank you very much for your very exciting presentation from each country. So, we found in Asia that each country has a very diverse set of programs in terms of clinical issues. In many countries, we found that the number of atrial fibrillation patients is increasing. But we also found that the situation completely differs in each country. For example, 80,000 cases of atrial fibrillation are performed annually in China and also in Japan. On the other hand, in some developing countries, atrial fibrillation has just started. So, my question is, what measures should be taken to increase the number of atrial fibrillation or other interventional procedures in these developing countries? I think that's a great question. Dicky, maybe why don't you take on Indonesia first? So, tell us a little bit about AF in Indonesia and sort of what might be done if, let's say, the AF ablation volumes are low or tell us a little bit about that. Yes, that's right. The problem is in Indonesia, the reimbursement is the key problem. But not only in reimbursement. We only have 42 electrophysiologists for a population of 270 million. So, you must imagine these 42 electrophysiologists who are able to do AF ablation, actually. But only 13 of them, actually, only 13 centers who have 3D ablation capabilities for a province, for Indonesia of 30 provinces. So, it's only in 12 provinces where these 13 centers are available. And most of the AF patients are only treated conservatively. So, only medication, medication, medication. So, ablation is only a fraction of patients who can get AF ablation. And only those with, maybe, who have private insurance. But the reimbursement for the national health insurance, it's not covered for the 3D ablation, including AF ablation. So, that is the main problem in Indonesia. Why there is not much ablation in Indonesia. Another issue is, as well, the awareness of AF. Most doctors or even patients are not aware of AF itself. So, we in Indonesian Heart Disease Society, we are still doing more and more awareness seminars for AF and it is still going on, but we still need to do so much for that. Yeah, I mean, definitely you can see that the second part of this discussion, you know, as we do go move on to the health policy issues is going to be really key here. Thinking about sort of how can we, you know, try to deliver sort of best care with limited resources, whatever the case may be. Minglong, you talked a lot about thinking about detection because Dickie brings up that point of increased awareness. What happens in China? Are clinicians aware of atrial fibrillation? Are they looking for atrial fibrillation? What happens? Thank you. I think it's a very important question for me to answer. But in China, we have started a lot of programs for AF screening and AF management. For example, I introduced four programs finished or ongoing in China. So try to screen all those patients. But these patients are in the communities or in the rural areas. So, for example, my program is focused on the rural areas for the older patients. So by these screening program, we can find a lot of patients with AF. But, you know, the AF management is almost blank. So we can start the AF management earlier than the final, the complications that occurs. So this is the a lot of programs. We try to extension our programs, our models to all the remote areas, because we train those local doctors via the online medicine to manage the AF patients. So each village doctor or each the doctors working in the communities, so they are in charge of fibrillation or any problems occur, they can, you know, seek the advice online from the AF specialists. So this is our program. So regarding to the different regions. So the doctor, Professor Shimizu just mentioned that how to take the measures to help those developing countries to increase the AF ablation number or to improve the patient care. So I think APHS started the program that's a country to country matching program. For example, Mongolia is matching to South Korea, so they can send their doctors to South Korea for AP training. And also, if they want to have some help, the South Korea can send some doctors to Mongolia to help them to do training and to do the demo procedures. So this is the country to country match program. The other program is we have, I think we have, Dr. Tachibane is here. We have, I think maybe two years or five years ago, we have selected 10 centers for training AP young doctors. So, for example, China here in my center, our center is one of the 10 centers for accepting the young AP physicians from different regions. So, but this year from Myanmar, the one young physician, his program was delayed because of the COVID-19. So I think these two programs can help those regions to improve their patient care. That's my opinion. Thank you. It's Andrew Cronier. Can I ask some of the other panelists a question about what happens after a patient has a stroke or an IA in terms of the extent of testing? So maybe we start with Professor Oh, what happens in Korea? For the AFF ablation, we have about 50 AF ablation centers and young doctors, especially young doctors, are very interested in the procedures. So we expect the total case numbers increased much very soon. And as you say, the AF awareness is very important. It's the most important issue. So we, Korean Heart Rhythm Society, are conducting programs for general population, such as SA competition. As Dr. Ming-Rong Chen said, South Korean AP physicians send some help to the Mongolian Heart Rhythm Society, but that's not still official program. But we are trying to change it to official program very soon. How about Andrew's question about stroke patients? Are they treated differently for looking for atrial fibrillation or is there any specific protocol? In Korea? Yeah. Okay. We don't have any special program, but we are following the general guidelines for anticoagulation. Okay. How about in Myanmar? Professor Nguyen? Yeah, thank you for participating in this panel discussion. And so we have many problems because our population is the 55 million population. And then we have only the general cardiology, well-trained cardiologists, about nearly 60. Among them, only 15 are for the AP training. So we have very limited arrhythmia service in Myanmar. Another option is that because as a developing nation, and then we have the many cases of rheumatic fever and rheumatic vascular heart disease is still present. So the atrial fibrillation is, most of the atrial fibrillation cases are due to the chronic rheumatic vascular heart disease. And then looking at our life expectancy, life expectancy is about 67. So then the other, non-papula AF, prevalence on non-papula AF is very low. And after the AF screening in program together with the Hong Kong, and then we have the prevalence of AF is among the after the 65 years is about 10 to 11%. So the arrhythmia service currently we provide is for the very simple procedure like the SVD ablation and then single chain pacemaker implantation is provided by the government side. We do not have the systematic reimbursement system at the moment. And then another problem is the insurance problem. So we do not have the proper Medicare insurance for the general population. So we have the private insurance for the people who have the interest. So that's a lot of problem. And another problem is anticoagulation. Anticoagulation is for the atrial fibrillation, very difficult to systematically monitoring of the anticoagulation therapy in the remote area. So we need to bring more healthcare providers for the antiarrhythmia drugs and then as well as for the anticoagulation. Another issue with the burden is for the coronary artery disease because of the increasing prevalence of the cardiovascular risk factors. And then the primary PCI service is only available in the tertiary care center like the Yangon, Mandalay and Mepidong and the rest of the country and they stay using the thrombolytic therapy. So management of the heart failure is also the major issue because the guideline-directed therapy is not available in the whole country. So only the guideline-directed medical therapy is only for the very small, available at a very small population in the city. So these are the many problems. We need to train more people for the cardiology as well as for the electrophysiology. Another huge gap is the training of the technician because we do not have the technician for the healthcare provider and the Ministry of Health. Thank you. Thank you. I mean, really we can see that maybe there are going to be some ways that we'll all be able to collaborate to sort of identify best ways to do things. And Tatchapong, you've multiplied. Please introduce your colleague and maybe tell us a little bit about what's happening with atrial fibrillation in Thailand. Hey, great. This is Sirin. Everyone knows her. I think we just shared a link. So my link is on his. And it turned out that he is the only one that can show his face. I'm like, wait, where's real Sirin? I'm not Sirin. Thanks for having us today, Fred. AF in Thailand, like I said, is growing. And we don't have enough EP, you know, minds to ablate the AF. So we hope with the, you know, setting up of the fellowship program, we can have more EP teams to ablate the AF. I have slightly additional view on this. I think maybe ablation, I think we're going in the right direction. But maybe, you know, Thai people do not complain a lot about it. I don't know why. But I think for us, as we progress to, I think more importantly, is the stroke prevention. That's probably his first priority for AF awareness, rather than ablation at this point, I think at least for Thailand. And with the AFNet data, we can tell the patient that even though they don't have that many symptoms, we can still ablate and get some benefit of that. That's super. So tell us a little bit about sort of what are some national programs maybe that are going on, right, thinking about atrial fibrillation. I mean, everyone's talking about this. People talk about sort of, you know, you need to lose weight, you need to work on, you know, diabetes, hypertension, et cetera. So, Wataru, what happens in Japan? Are there any sort of programs that are national programs kind of looking at these sorts of risk factors for atrial fibrillation to try to treat them? And then we'll go around the group because I think that that might be a way that we can think about sort of what can we do sort of collectively to identify the things that work and don't work. Thank you very much for your nice question. So, in the Japanese Heart Research Society, a guideline, so their risk management of such as diabetes, hypertension, and their SAS are very important to prevent the progress of AFM. So we encourage to manage their risk factors and their comorbidities, like your ESC guideline. Yeah, no, absolutely. How about in China, Professor Chen? Are there any national programs thinking about the sort of management of these risk factors for atrial fibrillation? I know weight's a huge issue in the United States. Is it an issue in China? Yeah, it's also a big, big issue in China, because China is huge. So different regions, the, you know, the disparities is huge. So, in the eastern part of China, because this is a well-developed region. We try to, like what I just mentioned, to extend the ABC management pathway to the rural areas. So we have a lot of training courses, and also we try to expand this patient management system to those rural areas or the community districts. So, through this way, we try to pave the way for ABC pathway management. So, anticoagulation, the symptom control, and also the comorbidities, especially the diabetes, the hypertension, and those patients with hyperlipidemia. So, these patients are well-controlled, maybe. So, the turning around point, we are becoming, I think. Yeah, absolutely. You know, we focused a lot on atrial fibrillation. You know, I'll just go around the sort of the room, you know, is AFib the biggest problem that you face? I've heard also heart failure, right? But is it then bradycardia and devices, or access to devices, or ventricular arrhythmias? I'll start here. How about in Indonesia? Is AFib number one? And if not, sort of what's number one? And then if it is, what's number two? So, actually, we are still fighting for the risk sector for atrial fibrillation and heart failure, which is actually hypertension in our country. From our national research, the prevalence of hypertension is almost 50% in Indonesian population. Maybe because, and we did in our study in Indonesia, most, though we are an archipelagic island, we live on an island, and our fish consumption is quite good, but the fish is salted. So, there's a very high sodium consumption, which then increases the hypertension prevalence, and hypertension, as we know, increases atrial fibrillation and heart failure, and we are still fighting even. So, actually, hypertension and heart failure is the problem, and AF is also a problem because of that. And what is now challenging as well in Indonesia is devices. The problem is that the distribution of devices, even for bradycardia, is very difficult because of the situation of those many islands and the implanters. We only have 1,000 cardiologists, and of these 1,000, not many of them are confident to place a pacemaker, or most of them maybe are able to place a single-chamber pacemaker, but more than that, it's only lifesaving in most cases, single chamber. But even that is not available in many islands in the rural area. So, probably, I would say what is the most problem in Indonesia right now is heart failure, of course, and bradycardia because of the not availability of the devices. Yeah, I mean, it's incredible to think about, you know, your country and just the geographical constraints that happen just because of, you know, the different islands, at least in the United States, even though, you know, we have 50 states, a big country, or in China, you know, at least it's confluent, you know, you're not having to get into a boat. Noy, you had mentioned in Myanmar that heart failure is a big issue. Do you have this 50% prevalence of hypertension in your adults, similar to in Indonesia? Yes, we do have the problem with cardiovascular risk factors. And in the community, the hypertension is 25 to 30% in the community in the previous study, based on the available study. So the diabetes is about 11 to 14% in the community and smoking is only 12% in the community. These are the major risk factors for the cardiovascular as well as for the atrial fibrillation. So what is the current project for the management of the NCD is we, under the WHO, is training for the band package. Band package, it means the essential transport, the package for the essential transport, the NCD. So now we have the state training for the remote area for the healthcare providers for the giving the treatment for the hypertension, the diabetes mellitus, and then healthy lifestyle. So these are the major issue in Myanmar for the prevalence of the, because of the not the totally control, the totally medication for the people in the remote area. So that is a problem. So that is why we are raising the number of the coronary artery disease, stroke, and then the heart failure. So another issue is the major issue for the fibular heart disease with the rheumatoid fever with the atrial fibrillation, pulmonary hypertension. So the other issue about the congenital heart disease, and I think the congenital heart disease is under detection because of the screening of the congenital heart disease is not well established yet at the moment. So these are the major issues. For the atrial fibrillation, the major challenges for the atrial fibrillation is the anticoagulation therapy. So anticoagulation, for example, for the new egg, availability of the new egg is very difficult, very expensive. At the moment is that we do have the original drug as well as for the generic drug from India. And then this is another, another promising and promising, but once for the having the anticoagulation. These are the problem. Thank you. Yeah, I mean, really just striking. How about in Korea, Professor Oh? Yes, I think the present is the year of big data. So I'd like to say my country's National Health Insurance Database. We generate actually many data such as risk factors using the Korean National Health Insurance Database. It has, it consists of five databases such as national health screening and health care utilization and so on. And interesting thing is all insured Koreans aged 40 years or older and their dependents are recommended to undergo biannual general health screening without cost. And participation rates of the general health screening program is around 75%. So the strength of this information database is one of the largest claim database, almost more than 50 million people, and it has the health screening information, and it is also a customized court data set, and it has mortality data, and it has resident registration number. So we expect we can generate more useful data using this database. In case of CID implantation, Korea has relatively low rate of CID implantation rate, but we still don't know the reason. And I think this issue will be touched in the next health policy issue session. Thank you. I think that that's absolutely right, and boy, you know, we're going to have to get some lessons from you, because again, you know, Korea, as you point out, clearly has this amazing database. I mean, you know, you think about early management of atrial fibrillation, all these other, you know, types of things, and I bet you we can learn a lot on sort of what worked and sort of what didn't, you know, in terms of developing that national database. I think incredibly valuable and something that will definitely come out of this discussion that we have started to hear. And Taiwan as well. Yeah, absolutely. A hundred percent. Tachibana, anything that you want to, either you or your colleague is joining us. Rin is like, Rin is supposed to be here, like somewhere in another room. Yeah, she's working on it. I can see her partially. That's exactly right. But tell us about Thailand. So is AF the big sort of issue for your country, or what are the other sorts of big players, and is there some underlying type of thing, like Dickie brought up, hypertension, that really is sort of the underpinning of causing issues? Certainly, I think in Thailand, people start to get more of these comorbidities, starting from like hypertension, overweight, start to becoming a big problem. I guess we quite good with smoking and things like that. So not too bad. Alcohol is a major thing in Thailand too. So these are, you know, is a cause of many cardiovascular disease that follows, you know, those rheumatic heart outside of Bangkok are relatively quite prevalent, not too much in Bangkok anymore. So not much more. So yeah, I think anything is a problem when you think about it. No, it's so true. I mean, again, it's all things sort of, isn't it? That's for sure. As we get more, I don't know, all these more food, fast food, getting better. Well, it's so true. I mean, you think about the, you know, sort of exporting McDonald's, I don't mean to disparage them straight away, but all the fast foods, you know, throughout the world, I mean, it's easy to inconvenient that, you know, for hairy parents and things like that to get the food quickly, but, you know, really not the best for diet. Meanwhile, how about in China? Is atrial fibrillation the primary arrhythmia problem, or what else is there? Or is there something that is important that we need to ensure that we address? Yes, the AF I think is one of the biggest problems, but currently the other important thing is sudden cardiac death. So for AF fibrillation, I think this is a real mature technique in China because the case volume, you can see that maybe at the end of 2030, the total case volume will be 300,000 in China. So for example, our single center, the annual case volume for AF fibrillation is 1500. The overall ablation case volume in our center is over 3000. So for ablation of these common arrhythmias, I think this is not very, not a big issue, but the big issue here, I think in China, maybe in other Asian countries, that's the sudden cardiac death program. So the estimated number of sudden cardiac deaths annually is around 500,000, so half a million. But as compared with this number, the ICD implantation in China is only around 5,000 each year. So this is a big gap. So I think try to save those lives by how to select those high risk patients with sudden cardiac death and educate the patient to accept these life-saving devices, and also working with the government to improve the reimbursement system to improve the patient care. I think these are the problems we need to work. So I think maybe other countries like Thailand, maybe Korea, maybe other regions in the Southeast Asia, sudden cardiac death is a big problem. What do you think, Dr. Phong? We've been focusing a lot on atrial arrhythmias, sort of, you know, obviously, you know, Thailand has a significant sort of sudden cardiac death with regards to channelopathy and other sorts of things. A big issue in your country? Well, it is a big issue, but I think, compared, I guess this may be personal, but I think, you know, people die suddenly, they die suddenly. But people who suffer a stroke, they suffer for longer times, and actually might be even more burden to the healthcare system. So personally, that's why we picked to do AF awareness first before sudden cardiac death awareness program for our population. But I think this reflects, you know, we've been talking about it. I mean, you can see that there's so much heterogeneity with regards to sort of where countries are with regards to resources, etc., that we'll have to get at the, you know, sort of at the second portion of this. So why don't we do this? Because it does sound like a lot of these issues do sort of spawn from these health policy issues that we all have, you know, to face in each of our countries. And why don't we go ahead, we'll stop just a bit early. We actually have a couple of additional people, and Dr. Khan, who hopefully is going to be able to provide information live at the very end of the health policy portion. So why don't we go ahead, take maybe a few minutes, five minutes or so off, and then we'll go ahead and start with the pre-recorded portions on the health policy portion of this summit. And I know we're going to have a robust discussion. So, panelists, I look forward to chatting with you again in a bit of time. So we'll go ahead and go to those videos in about five minutes. Take care. You know, we've had a really robust discussion about the clinical issues that face all of the different countries in Asia. And now we're going to hear about the health policy issues. So we have a series of videos that have been queued up, and we'll go ahead and get started with that. And then afterwards, I know we're going to have an incredibly robust discussion with regards to health policy issues. And that will be led by my friend and colleague and the program chair, Jodi Hurwitz. The field of electrophysiology in Thailand is well-established and still actively growing. My name is Sirin Appiasawat. I'm representing the Thai Electrophysiology Club. I'm here today to talk about the health policy issues in EP field in Thailand. The most important policy issue in any medical field in Thailand, including EP field, is the reimbursement policy. In Thailand, almost all citizens are medically insured. Seventy-five percent of them are insured by the insurance package called Universal Coverage Scheme, or UCS. It's provided by the government. It's a pro-poor, non-contributory policy, meaning that the patients don't have to pay any premium fee, don't have to co-pay for any services or any prescriptions, as long as those services and those medications are in the list to cover by the scheme. In 2012, the coverage package expanded to include the dual chamber pacemaker, the ICD for primary prevention, CRTD, and the 3D mapping for catheter ablation. As a result, the number of EP procedures jumped significantly. More doctors, more young doctors, would like to become an EP electrophysiologist. On the other side, for those procedures that have yet to be covered by the UCS policy, the numbers are extremely small. For example, the leadless pacemaker cover only 20 percent. In some cases, not covered at all. As a result, the number of leadless pacemaker are extremely small compared to the numbers of overall conventional pacemaker. And, I mean, we have been doing leadless pacemaker since 2016, so the procedure itself is not extremely new, and the expertise was not the problem because we've been doing this for many years. The same goes with the subcutaneous ICD and the cryo ablation. Beyond the reimbursement policy, the facilities and workforce are number two and number three policy problems in Thailand. Facilities and workforce actually in Thailand go hand in hand with each other. Why is that? Because there remain significant numbers of tertiary care hospital in Thailand that have no electrophysiologist and have yet to equip with EP equipment. So, whichever comes first could feed the other side. For example, if they have more EP doctors, hospital would buy more EP equipment. Regarding the number of procedures, the trend is going up, but the absolute numbers are relatively small. Showing here is an annual number of procedures per one million population. You can see that the complex procedures such as AF and VT ablation, the numbers remain small, even though it's increasing. We are seeing this number, you know, would continue to increase because we recently developed the EP bot training and EP fellow would be more, we can see more EP fellow get certified, have a newer standard, and performing more of these complex procedures. What else have the Thai EP club done for the reimbursement policy? We filed for the new items to the government body, and this would take years to be effective. For facility and workforce, we established fellowship training, and we continue to support the training for EP tech both nationally and internationally. In summary, EP field in Thailand continues to grow. Major limiting factors is the reimbursement policy, and Thai EP club is actively involved in, you know, trying to resolve that problem. Thank you very much. Thank you, Mr. Chairman. I'm Jongil Choi. I would like to present a health policy issue in South Korea on behalf of Korea Heart Rhythm Society. The 10-year trend of out-of-hospital cardiac arrest in South Korea, the incidence of OCAR has been rapidly increased during the past decade. One-year mortality rate after OCAR is still high, but gradually decreased. Current artery disease is the most common cause of sudden cardiac death. However, sudden unexplained death syndrome, the proportion is significantly higher compared to westernized country. Sudden cardiac arrest instance is also affected by hospital accessibility, like this rural area, higher instance compared to urban area. Annual number of new implantation in Korea rapidly increased during this year, especially at the point of guideline and reimbursement indication update. Interestingly, the patient with ischemic cardiomyopathy, the primary prevention rate is still low, and so we need to focus on these patients to grow. As you know, there is asymmetric information between physician and patient that may cause supply-induced demand, and so leading to overuse in healthcare system. And so, some physicians provide more care than their patients, and because of defensive medicine, financial incentive, lack of understanding of a diagnosis test, growing trend of research-driven healthcare industry, like clinical trial, and regional difference in clinical practice. And so, I suggested these solutions in order to overcome the problem, and government mediation system, fair assessment system, definite indication by updated evidence, audit and conflict of interest disclosure, and international collaboration, including multinational clinical trial or guidelines from regional society. And so, since 2016, in Korea, pre-evaluation system for reimbursement before ICD implantation under Korean government, the physician can submit monthly before test day, limited to ICD or CRTD. This is a peer-reviewed system by EP specialist committee. The most cases are secondary closure of sudden cardiac death, so primary prevention. Doctor's statement of opinion is most important to document, and also the medical record and the ECG, and any kind of evaluation or laboratory finding is important. This is the APHRS White Book 2012 in South Korea for ICD implantation, and during COVID-19 era, ICD implantation rate gradually decreased. And interestingly, since after pre-evaluation system of reimbursement for ICD, the case of total ICD number rapidly increasing like this. In summary, in Korea, access to care in sudden cardiac death is a very important problem of an area in a rural area. In the primary prevention, patients with ischemic cardiomyopathy, we need to focus on these patient population for the therapy availability. For addressing an issue of reimbursement in Korea, adopt a pre-evaluation system before ICD implantation. Thank you so much. Thank you very much. Hello, and good evening. This is Diki Hanafi from the Indonesian Heart Rhythm Society, and I would like to present to you the health policy-related arrhythmia services in Indonesia. I would like to thank the Heart Rhythm Society for the invitation. It is an honor to speak here. Low and middle income countries like Indonesia are coping with a high burden of health problems and unmet health care needs. Indonesia spends only around 2 to 3 percent of its gross domestic product on health. Therefore, despite being a major burden in public health, cardiovascular diseases, including cardiac arrhythmia, are not really the priority in health policy. Indonesia is the largest archipelago in the world, with an estimated total of 17,504 islands. It is located between two oceans, the Pacific and the Indian Ocean, between two continents, Asia and Australia. The population consists now of more than 217 million inhabitants. In the past couple of decades, Indonesia experienced a rapid economic growth. This is also presented in health improvements such as decrease in life expectancy, decrease in rate of infant and maternal mortality. As a consequence, Indonesia also experienced a rapid epidemiological transition in terms of current and projected disease burden. Cardiovascular disease is number two as cause of death, while stroke is number one. Historically, the Indonesian health care system was largely fragmented and made up of a mix of private insurance schemes and out-of-pocket payer for those who could afford it, basic state provision for the poorest, health insurance for government employee called ASCAS, a non-governmental organization that provided specialized health care in between. In 2008, the DISG system was implemented to improve reimbursement and more efficiently to address this fragmented system and resolve the country's health care inequality. The Indonesian government introduced the national health care system in 2014. Today, around 92% Indonesians are covered. It is the world's most extensive insurance system. Meanwhile, private insurances are estimated to cover only 6.5% of the Indonesian people. However, minimal reimbursement is an issue for cardiac implantable electronic devices and ablation procedures, which are only enough for single chamber pacemaker and simple cardiac ablation utilizing reuse catheters. The lack of funds for complex procedures that are not met will be a burden for the hospital because NHS participants are not allowed to contribute additional costs. Those procedures include implantation of dual chamber pacemaker, high power devices and 3D ablation. A common issue in developing countries is the scarcity of cardiologists. There are only about 1,000 pro cardiologists serving a population of 270 million people, which are also contributed unevenly. Cardiac electrophysiologists are even more scarce. Currently, Indonesia has only 42 EPs. Furthermore, of these 42 cardiac EPs, in 14 EP centers serving a population of 270 million people, they are all distributed unevenly, located in 13 of our total 34 provinces in Indonesia. Complex ablation procedures can only be performed in less than 50% of those EP centers. Also, the availability of arrhythmia drugs and its distributions are another challenge. Here's a comparison of the procedures compared to Japan, undermining the underserved population for arrhythmia services in Indonesia with a population of 270 million compared to Japan with a population of 120 million. Our efforts now, there is ongoing approach to the government from the Indonesian Heart Association for better classification and reimbursement. In addition, the role of private insurance is continuously pursued, especially for coordination of benefit and patient deductibles. One thing that I would like to stress out is the minimal training opportunities in Indonesia for electrophysiology. And I would like to ask HRS and APHRS to assist Indonesia in this process. To assist Indonesia in giving training opportunities for young cardiologists who are interested in EP. Thank you very much for your attention. My name is Martin Stiles and I'm a cardiac electrophysiologist from Hamilton, New Zealand. Together with my colleague, Dr. Matthew Weber from Wellington, we've been asked to put together a brief presentation about health research policy in New Zealand and how it pertains to the electrophysiology community. New Zealand is a country of 5 million people and we have four main centres for electrophysiology activity. That's Auckland, Hamilton, Wellington and Christchurch. In addition to that, we have pacemaker and planting centres in other parts of the country. And we've recently welcomed Tauranga to the electrophysiology community with the purchase of a new lab there. Most healthcare in New Zealand goes on in the public sector. We have a comprehensive public health system which covers everybody for their general health needs. In addition to that, about 35% of our 5 million population carry some degree of private health insurance. And that allows some people to take their care in the private sector. New Zealand are undergoing some quite significant health reforms that will take place on July the 1st this year. We're moving from a 20 district health board model throughout the country to a single health board that will cover New Zealand. This will work in parallel with the Maori health authority who will represent the indigenous people of New Zealand, the Maori. In New Zealand, cardiovascular health, of course, has to compete against other health needs. And within cardiovascular health, electrophysiology competes with other parts of cardiology. So competing with lab access for angioplasty, structural heart disease, and some echo procedures. Even within electrophysiology, there's a competition for lab space as many of the labs that are used in New Zealand do both electrophysiology and pacemakers. Thus, if the pacemaker load is heavy, not a lot of electrophysiology procedures get done and vice versa. But because of the acute nature of pacemakers, we often find that we're struggling to find time to do electrophysiology procedures because of the sheer workload from pacemakers and ICDs. In New Zealand, we put in 2,670 pacemakers last year, and we put in 350 CRT devices, which were made up of 210 CRT pacemakers and the remainder CRT defibrillators. We put in 457 ICDs across the country. Most of these were news, but of course, some of them were box changes. And we did over 2,000 EP procedures throughout the country. Of these, the biggest group was SVT making over 900 cases, but it was closely followed by atrial fibrillation, which comprised 730 cases. Throughout the country, there are 21 doctors who can perform pulmonary vein isolation and a similar number who can do structural VT ablation. One of the big limitations that we find in New Zealand is the workforce, particularly physiologists. We rely heavily on our physiology colleagues to run EP studies and make sure that things are being done correctly, supporting us to do the work that we can. We do have supportive industry who can come and help us, but I think that growing our own health workforce is extremely important. New Zealand runs fellowship programmes with each of the four main centres having an EP fellow training programme. We've trained both New Zealanders, many of whom have stayed in the country and gone on to senior jobs, but we've also had visitors mainly from the UK, from Australia, other parts of the world who've come and trained here and then gone back to their home country. Throughout the year, we have Health Awareness Day such as AF Awareness Day, Heart Failure Awareness, and we're often supported by the New Zealand Heart Foundation. We get a lot of research done in New Zealand, a little more than I think we're funded to do, but as one of my famous science colleagues, Sir Ernest Rutherford said, if you don't have the money, you're just going to have to think. And I think that really sums up New Zealand. We don't perhaps have the resources of some of the larger countries in the world, but we do the best that we can with what we've got. And we do that by thinking hard, we're going to be growing our workforce. We're going to be continuing to do EP studies and expanding as best we can within the constrained health service of a public system that we work mostly in. Many thanks for listening to me. I hope you enjoy the rest of the presentation. Ladies and gentlemen, it's my greatest honour to participate in this summit. My task for today is to discuss the health policy issues in Taiwan, focus on access to care, therapy availability, and the reimbursement. First of all, I want to mention briefly the national health interest in Taiwan, its impact on the healthy policy. The characteristics of Taiwan and HOI, including the universal coverage, is about 100% coverage rate. And it is a single payer system. We have one boss, it's only our government. And it has reinforced the referral system by using the copay. And most important for the study, we have NHI big data and the digital health. This system has some advantages. The first, it is very convenient and provide good accessibility to health care of the patient. And the second, it's cheap and abundant coverage. The third, it's a high coverage rate because it is mandatory for citizens of Taiwan living in Taiwan or overseas. This slide shows how Taiwan Registry and NIH influence the cardiovascular patient care. We have some hard registry undergoing in Taiwan, including the atrial fibrillation and the sudden arrhythmic death syndrome. By this registry data, we can get the real-world practice data and find the low anticoagulant reuse and the unknown disease pathogenesis. Therefore, we can improving this data by some strategy. The first, we can request the insurance policy changes to NHI and we can set some, provide some education program for the physician in addition to the patient and the family. By this way, the outcome can be improved because we improve the guideline adherence and we can underline the rare disease cause and the improved quality of cardiovascular patient care. Our colleague published this paper in the real-world experience because the NHI totally covered the cost of NOAC. Therefore, when the NOAC was launched, the use of NOAC increased rapidly in Taiwan and disseminated very universally. And the increase in the NOAC use, the decrease the warfare use, which can translate to the improvement of clinical outcome, including the decreased mortality, decreased ICH and the decrease that is chemical stroke. Of course, this system also have some challenges. The global budget and the predominant fee-for-service restricted the interventional therapy and the delay the new devices application. Second, the guideline-based therapy in very rare conditions, especially with the high-priced device is not fully accomplished due to the reimbursement decision. The reimbursement of device, for example, is designed by the NHI administrator with the balanced feeding system. And the coverage decision can classify as reimbursed and the funding under procedure fee and the unreimbursed. In addition, the decision about the single-use device are often made without the clarity of procedure and the process. Therefore, we can see the data of Taiwan in 2020. We can see the cardiac implantable electrode device, the pacemaker, the CRTP, CRTD, and the ICD number here. And you can find the most important is in Taiwan, the primary prevention for ICD is only 1% because it's not under the reimbursement policy of NHI. In addition, the data concentration is very rare. On the other side, the CAST operation procedure is showing in this slide. You can see the AFib operation is far less than the SVT operation. Thank you for your attention. Thank you very much for giving me the opportunity to present. My name is Kyoko Soezima from Kyorin University School of Medicine, Tokyo, Japan. There are two major health policy issues in Japan. One is sustainability of universal health coverage and the other is aging society. Universal health coverage was attained since 1961 and allows every citizens unequal access to a necessary and high quality medical treatment by paying only a certain percentage of the medical cost. It ensures unrestricted access. Patients are able to receive care at any medical facility throughout the country. This universal health coverage is a wonderful system, but there are sustainability concerns. The current healthcare system faces various issues, increasing the elderly population, decreasing the working age population, and the burden on the healthcare system caused by a pandemic. There is a need for emergency and expensive treatment. The social security costs continue to rise. Between 2008 and 2013, healthcare spending increased from 8.5 to 10.2% of the GDP. This is higher than OECD average of 8.9% in 12-13. Japan is one of the largest medical device markets, estimated in 2012 at $32 billion. The market size is expected to grow given the aging population. Other reasons for the increase of social security costs are longer hospital stay compared to the other OECD countries and lower generics share in Japan, 28% compared to 48% in OECD average. Between 2010 and 40, the population aged 65 and over will increase by 9 million and the population under 65 will decrease by 30 million. Starting around 2040, growth in the older population will plateau while the working population will sharply drop causing the overall population to shrink by 15%. Cause of death is shown here. Although cancer is a leading cause of death, heart disease continue to increase. With combination of stroke and heart disease, it is compatible with cancer. This slide shows the estimated incidence of heart failure in atrial fibrillation. As you can see, the incidence of new onset heart failure in atrial fibrillation continue to rise. Due to the aging population, deaths from non-communicable disease, NCDs, increase. NCDs include chronic disease, including cancer, diabetes, cardiovascular disease, respiratory disease and mental health that are caused by unhealthy diet, lack of exercise, smoking, excessive drinking and air pollution. In Japan, about 82% of the total number of deaths are due to NCDs. Therefore, the Japanese government has formulated treatment plans in 2008 for medical practitioners. Specific health examinations and specific health guidance in an effort to tackle lifestyle diseases which are causal factors in approximately 60% of deaths each year in Japan. Improvement of healthy life expectancy, not life expectancy, is warranted. Also, the Stroke and Cardiovascular Disease Control Act was enforced in December 2019. It aims to promote the prevention of stroke, heart disease and other CVDs while advancing the development of a system that provides rapid and appropriate treatment to extend healthy life expectancies and reduce the financial burdens of medical treatment and long-term care. It emphasized the citizen education and prevention. This slide summarizes the issue and the plan of the health policy in Japan. Thank you very much for your attention. Greetings from Myanmar. I am Nguyen Hue, country representative of EPHRS. I'm going to present the health policy issues in management of cardiac arrhythmia in Myanmar. These are the major issues for health policy in management of cardiac arrhythmia in Myanmar. Reimbursement and payment system, arrhythmia service facility, including technology and equipment, workforce and HR training, access to the medication and interventional procedure for management of cardiac arrhythmia. Regarding the reimbursement, countrywide reimbursement program for population is not established yet. There is a partial reimbursement of the healthcare cost by social welfare service for employee from the Ministry of Labor. People can have private Medicare insurance seen by their interest. Regarding the arrhythmia service facility, government provides the immediate infrastructure of EP lab for conventional EPS and phasing procedure. Highly advanced technology and equipment are far fetched. Currently, EP facility are available at three public hospital and one military hospital. Electrophysiological service and phasing facility at private sector is under development. These are the three public hospital equipped with the EP system and one military hospital. Regarding the HR training and workforce, total 15 well-trained EP doctors are serving for the 55 millions of population. We need for more EP doctors to be trained. There is a huge gap in the training program for allied professionals for electrophysiology. There is a scale knowledge gap on availability of arrhythmia service there. It is partially solved by refresher course for the remote working junior doctors. Regarding the access to medication and interventional procedure, there is a gap on the availability of arrhythmia service for people in remote area. Conventional ablation procedure and single chamber pacemakers are available in public hospital with a cost-sharing manner. And the arrhythmia drugs and antiregulations are available during hospital stay, but continuing treatment is at patient-owned cost. Long-term antiregulation therapy and monitoring causes major healthcare problem. Despite several limitation, EP doctors in Myanmar are providing service as utmost effort for sustainable and up-to-date management of arrhythmia. Thank you for your attention. The Philippines is an archipelago made up of 7,460 islands. This in itself is a challenge as some underserved provinces are separated geographically from the more affluent city centers, not just by distance, but by water as well. Inequality can be seen in the city centers, with 23.7% of the population living below the poverty line. Most healthcare spending is out-of-pocket, which means even the poor have to dip into their meager savings whenever they or a family member are hospitalized. Like many countries, the Philippines struggled through the COVID-19 pandemic, but the healthcare community and the citizens persevered and we are currently in a position of recovery. As the current state of arrhythmia management, cardiac implantable electronic devices such as pacemakers and ICUs are available in the country, but most of the facilities in which these devices can be implanted are in the city centers, particularly in Metro Manila. Rager frequency ablation and 3D electroanatomical mapping equipment are available in the larger hospitals and cases are slowly increasing. However, a lot of patients are unable to afford these expensive therapies. While arrhythmia therapies are available, we suspected that they were largely underutilized. The Philippine Heart Rhythm Society wanted to look at the data available to us to describe the utilization of cardiac implantable electronic devices or CIEDs and rager frequency ablation in the country. The group decided to look at the records of our national insurance, PhilHealth. A few notes about PhilHealth. The government aims to automatically include all Filipinos in the National Health Insurance Program through the Universal Health Care Bill. However, PhilHealth only partially covers the cost of hospitalization in its current iteration. For example, it only covers 10% of the pacemaker implant. Looking at the PhilHealth database, we saw that there were 1,121 and 1,149 claims for hospitalization for supraventricular tachycardias in 2017 and 2018, respectively. This represents 4 hospitalization claims for SVT per 10,000 of the total claims. However, only 25 and 19 patients underwent rager frequency ablation in 2017 and 2018, respectively. This means the utilization rate of rager frequency ablation is 0.04%, and that most patients with SVTs either take medications to suppress their arrhythmias or are not taking any treatment at all. For bradyarrhythmias, there were 958 claims for various kinds of symptomatic bradyarrhythmias in 2017, and 1,144 in 2018. The estimated prevalence of bradyarrhythmias for both of those years was 0.04%. However, when we look at the number of pacemaker implantations, 549 in 2017 and 683 in 2018, we see a big gap between the number of cases requiring a permanent pacemaker and the number that underwent the procedure. In 2017, 1,282 individuals were admitted for dangerous ventricular arrhythmias, 1,418 in 2018. The estimated prevalence of ventricular arrhythmias based on the National Insurance data is 0.05% to 0.06%. Only 50 and 45 patients underwent implantable cardioverter defibrillator or ICD implantation. In 2017 and 2018, respectively. Given that some of these implants are probably primary prevention devices, the data strongly suggests that there is a very wide gap between the prevalence of cardiac arrhythmias requiring an ICD and the frequency of implantation. Nearly all the ICDs implanted in 2017 and 2018 were implanted in the Metro Manila area, again pointing at how underserved the rest of the country is when it comes to arrhythmia therapy. So what is the state of arrhythmia management in the Philippines? While CIEDs and RAF ablation are available in the city centers, the therapies are underutilized, likely because most of the population are unable to afford the cost of the procedure. The current case rates or coverage of the National Insurance Program underestimates the cost of the therapies and is unable to make these therapies accessible to a wide range of the citizenry. Hopefully changes enacted by the Universal Healthcare Bill will narrow the gap. Professor Khan, are you on? Yes, I am on. Thank you so much for joining us live. Good morning there in Pakistan. Good morning to you all as well. Absolutely. I'll let you go ahead and get started with your health policy discussion and issues that your country faces and then we'll start with the panel discussion. So the floor is yours. Okay, so thank you. So we are relatively young in the society, so I'm going to give you a perspective on healthcare delivery in Pakistan. So we are the fifth most populous country in the world, a population of about 20 million. We have nine EP labs and these red dots show the fully potential EP labs and this orange one is a partial service. So if you see that we have five provinces and this is the most populous region in which you have these nine labs spread, there are 21 cardiac electrophysiologists. We have a College of Physicians and Surgeons that recognizes specialization and we have a fellowship program started as well. However, despite having these 21 centers, the service is patchy in the sense that there is a cost to services and rhythm services are not recognized as a specialty clearly at this point in time. So in terms of service availability, we have very limited drug therapy and you'll be surprised to know that in the antiarrhythmic arena, we only have Amiodrone, Lidocaine and some centers have Sotolol. We do not have other antiarrhythmic therapies. If cardioversion available, EP ablation, 3D mapping with cryoablation coming in a few of the centers. We do all sorts of devices, pacemakers, and his bundle pacing was recently tried in centers with Procter's. If you look at the map over here, you see population density and you see these green marks are the EP labs. They are along the most populous regions, but look at Balochistan where you can see my arrow if you can. This is the lower top and this is a very wide area. The population is less dense, but we do not have any facility over here and up top in Gilgit-Baltistan, we do not have any labs. People have to travel a lot of distance to reach the centers. Basic health units network in Pakistan is very good, but they're not men. Recently, public-private partnership was started and the things are better. We've recently had a regime change and policies change with the new governments, but in the previous government, a lot of work was done towards health. In one of the provinces, there is a concept of a sahid card, it's a social medical insurance that is given to each household, one million Pakistani rupees provided, and our goal is health care for all. Drugs, as I've said, serious non-availability of drugs, EP centers are available in three of the five provinces, device therapy is available in three out of five provinces, and there is also a problem that if we implant in one of the far-flung areas, then follow-up for the devices is also a challenge. And you can see the reimbursement is mainly out-of-pocket. And like Philippines, 24.3% of our population that's also below poverty line. Medical insurance for government employees, medical coverage for military personnel, then we have religious mandatory donations, which make part of the zakat system, welfare systems are through as well, and there's employees all benefit. But basically, up till now, majority of our patients go with out-of-pocket payment. Other than two provinces now which have the sahid card, which I have down over here, which is one million per family, that's where we stand right now. This was 2018, and for 2050, the plans were such, but the government has changed. So now we're waiting for the new policy to come through. So the national health vision, we had a rudimentary policy in 2001, which was upgraded under the auspices of WHO in 2009. And the vision of national health for 2025 is to improve health for all Pakistanis, particularly the vulnerable population like women and children. And this delivery should be through resilient and responsive health system. So the national health policy 2025 has been designed in line with WHO health care systems using their six thematic pillars. So this is the state of affairs right now. Thank you for allowing me to speak. Wonderful. Thank you so much, Amir. That was really outstanding. And we'll go ahead and get to the panel discussion here. And we have a couple of new people who have joined. So I'll get them to get on. See, they're on. Perfect. So I see, you know, we have the people who were with us previously. But Dr. Sevendy, I see that you have joined us. Do you want to say hello and introduce yourself? Oh, thank you for the invitation. My name is Dr. Saroj and I'm from Mongolia. Nice to see you. Thank you very much. We really enjoyed your discussion about the issues in Mongolia, particularly thinking about, you know, access to care. And actually, you were thinking, you know, provided some provocative ideas and how we can provide sort of better training. And again, collaborate along the region. I'm going to turn it over to Jodi Hurwitz, who's the program chair for Heart Rhythm 2022. She has a fair number of questions with regards to health policy issues. Yeah, thank you very much. Yeah, this was a really excellent initial conversation. I think that there's a lot more that we have to do and a lot more conversation that we have to have. I think one of the most one of the most interesting ideas is all about in each location, what the national health care insurance actually, well, what it's trying to provide. But one of the questions is, what will it really provide? And I thought that one of the interesting things about Japan was, in fact, how they're looking ahead in terms of how to treat their aging population, perhaps so that there'll be a little less use of the health care dollars. And I was wondering if we could start with a conversation there so that we can try and figure out how we can all learn from this. So, Wataru, what's happening in Japan? OK, thank you very much. So I enjoyed very much the presentation from all countries. So in Japan, the basic act on measures against stroke and cardiovascular disease was enacted in 2019. And this role, as well as Japanese Heart Rhythm Society and the Japanese Circulation Society, would emphasize the importance of improvement of healthy life expectancy, not life expectancy. In Japan, the life expectancy is 91 years old for females and 85 years old for males. A healthy life expectancy is a lifespan that can be spent in good health without repeated nursing care or hospitalization. So in Japan, a healthy life expectancy is more than 10 years younger than life expectancy. So it is very important to prolong the healthy life expectancy. So for this purpose, once again, stroke prevention and management of heart failure are very important. And atrial fibrillation has a significant impact on both stroke and heart failure development. So once again, we need to take care of atrial fibrillation to prevent stroke and develop heart failure. Right. And I think in South Korea, also, there was comments that there was a very strong national health care policy. But yet there seems to be some significant disparities in terms of access to care in specific locations. Any comments on all of that? I think Professor Oh stepped off for a minute. OK. Thanks. The other interesting thing, and I think that you alluded to this, is how each of our organizations needs to play a significant role in helping along all of these policies and how they're going to be enacted. I'm wondering if any of you all can comment on how you've looked into all of this and where we all can work together towards something that's more universal. We can start with Japan. Yeah. Wataru, why don't you go ahead and start and then we'll sort of move on to Pakistan and then Mongolia and then to Thailand. How does that sound? So Wataru, how about national health policies? Yeah, in Japan, the national health policy is our, so especially we emphasize our management of the coronary cardiovascular risk factors and our prevention of comorbidities such as heart failure, hypertension, diabetes and hyperlipidemia. And also the alcohol consumption is reduced. Yeah. Great. And Amir, how about in Pakistan? Yeah, so we have a lot of problem over here. So we are a new society. We've not kind of found our roots in policymaking. We are trying to be recognized as a body so that we can have conversation with the government. So these are parallel systems running. Now, with the Sehat card coming in, this was going to be something very remarkable, but the regime change has kind of put it on hold. Over there, you know, they were providing money, one million per population, and they were further trying to augment it through other medical insurance so that people could have these devices are very expensive over here. And we are spending very little per capita on health issues and education. So we're trying to improve that. Secondly, I showed you that we have about nine centers out of which about four or five centers have cryoablation facilities and people who are getting training. But atrial fibrillation largely over here is rheumatic. So it's not the kind that, you know, you go in straight away for ablation. We have not yet taken care of the conventional SVT ablation or, you know, so so there's a disparity. So we are just trying to find our feet and trying to get whatever resources we have pulled together. There is paucity of data. It's very, very variable and it's not credible that I can build my, you know. So, so, so there's a lot of challenges for us. Can I ask a question? Yes, go for it. So, so in in both Europe and North America, there are also patient organizations that can be quite vocal about the benefits of care or testing or recognition or treatments. And in many instances, governments are more responsive to patients or the public or the voters than they are to the medical community. So I'm sort of curious whether there are any patient groups within your countries and organizations that can help to raise awareness. I think that's a great idea, Dickie. What's happening in Indonesia? Is there sort of patient groups? Not really. So, well, our national health care system is quite new. It's just started in 2014 that everybody in Indonesia is covered for medical procedures and for and for the cardiology. The Indonesian Heart Association, in conjunction with the Indonesian Heart Society, are now lobbying the Ministry of Health and the National Health, Universal Health Care to increase and to expand their coverage. You can understand that, for instance, for CID, they only pay, which is only enough for a single chamber pacemaker. And they say to the population, we cover everything, don't worry. But what they spend is only what is enough for a single chamber pacemaker. So if a patient needs ICD, needs CRT, it's not enough. But they say to the population, what CRT? Of course, we covered it. But the population doesn't know it is only actually enough. So it is then to us, the medical society, we now are lobbying that they increase this reimbursement and that the population can get the high power devices and even 3D ablation, which is, if we look at the reimbursement, it's only a fraction of the cost for 3D ablation. And it's only half of the cost for the conventional ablation. That's why we only can use reused catheters. So it's nowhere in the developed world are you using reused catheters. But we have to do that in Indonesia. We use them in Canada. As if we are in the developed world. I think that's probably more ubiquitous, but it's true. But I mean, I think that you both bring up a very good point, which is knowledge in a way is power. And the more education we can get to the population out there about what is possible, what can be offered and what is not being available, I think that's going to be very powerful. I think there's a lot of room for discussion here about how everybody can support each other for that kind of thing. Yeah. And I think that you brought up a good point. And I think that was the Thailand presentation also talked about the fact that there are definitely procedures that are covered. But the newer procedures, what we would call better coverage, is not being covered. It'd be great if people want to have any other comments about that. So what do you think in Thailand? Yeah, I agree with what Dickey was saying about the knowledge, I mean, you were mentioning about the patient's organization, which, I mean, we don't have it here, but I think the social perspective, social perception of the procedure of the devices are the most important thing to drive the government policy in Thailand. So, I mean, nowadays we talk about social media and that if you have a superstar die of Brugada syndrome, that's a big news. So people were gonna start talking about what the therapy. So I think the things that Heart Rhythm Society has been doing as well as Thai EQ Club is trying to put out video clip, showing in the social media is what our disease are all about. We are not the coronary artery disease, we're not the heart attack, we are sudden cardiac death, which is a lot more serious. So I think social media is one of the critical tool nowadays to improve the public knowledge and perspective of our disease. Can I ask a question to follow? Yeah. So tell me about that, cause you know, in Asian culture, I mean, it tends to be quiet and you know, is social media, are things changing sort of amongst sort of the younger generation? They're good at typing things, they're not good at expressing things. Thailand probably number one, number two in the world, top in the world in terms of social media engagement. So yeah, that's a big deal. It raises great points and your comment about sudden cardiac death. I mean, obviously we've spent a lot of time talking about atrial fibrillation and I think in a lot of ways, as has been expressed throughout this whole session, that may not be something that everybody is as much of aware of, but sudden cardiac death definitely is. So perhaps that's what we need to do is start changing a little bit of our message so that there are more people who are out there who understand that. The orange apple poster from Heart Rhythm Society was nice that you guys came up, you know, many years ago. I like it very much. Yeah. So I get a sense that maybe we're getting towards the end and I just had a comment, two experiences I had recently that I think could be helpful. The one, just like offer to anyone on the call, because we have such a large Asian population in Vancouver, many of our materials for cardiac care have been translated into multiple languages, including video as well as digital content. So if you want an explanation of Brugada in any of multiple languages, we have those materials and we're open access share. So just contact me, please. So the second thing is really more about the policy question and I'm just going to tell the story of something that started yesterday with Professor Sammy Viscan, who most people know. And Sammy emailed me as the incoming president of HRS to say that he has a patient he has been shipping quinidine to from Israel to Brazil, because you can't get quinidine in Brazil. And every time he runs out, he gets ICD storm and shots. And he's been doing this for so long, but the supply chain problem has come up and he's asking if either I could do something personally or HRS could advocate for access to medications. And it's a good question. It raises the issue of the fact that medication access to therapies include simple and generic and old medications. Quinidine is an example, but we heard in some instances you can't get laconide or propanone, which are also very old drugs in some jurisdictions. So I guess I'm asking the question for the group, to what degree is access to effective medications a big barrier, because that's a short-term simpler, non-invasive, more population strategy to try to address short-term needs than trying to build trained electrophysiologists and complex mapping system. You want to start there? Yeah, yes. That's a very big issue in Indonesia. As you say, like flakinate and propafenone, it is not available in Indonesia. It's a very old drug, but it's not available in Indonesia. We just recently have propafenone now, but flakinate is still not available. And if we talk about beta blockers, only bisoprolol and propranolol is available in Indonesia. Sorry, carfidilol is also recently available, but no metoprolol, not the other beta blockers as well. So only three beta blockers for Indonesia is available, propranolol, very old one, but bisoprolol and metoprolol. So even access of antiarrhythmic drugs is a problem. The only class three antiarrhythmic drug that's available is amiodarone, that's it. And if you go maybe to the smaller or the rural islands, they only have three drugs, antiarrhythmic drugs, propranolol, digoxin, and a little bit of diltiazem. That's it. Not much rhythm control. Not much rhythm. But you know what's really exciting about this, right? Only these three, so if you go, it's a really big issue in Indonesia as well to have this, and we are now trying to distribute these medications more efficiently to the rural areas. See, but that's what the value of this is, right? So we can develop a wish list, you know, sort of amongst everyone here, sort of what is the antiarrhythmic medication that you have? What are the ones that you need to have? And can we then, between APHRS and HRSN, begin to advocate sort of on a governmental level, right, to get access to those types of medications? I mean, I think that that's the value, because you know, people complain about this in isolation, but it's really trying to bring it together collectively where we can then use our powers together to then ensure that the access to different drugs and necessary drugs are equal throughout the region. I think that that's great. Before we close, though, we clearly have to deal with the work, you know, sort of force issue, et cetera. That's what I was gonna say. At the very end, I think one of the things that we really haven't addressed yet that you can just hear and is really very, very different in every country is the workforce problems. So may I chime in on this issue of drugs? Because we've been, you know, we only have Amiodarone. You have someone come in with a VT storm. So I go with flecainide and maxillitine, and it's available on the black market. You know, it's been smuggled into the country. Wow. And- Amazing. Yeah, we have the same problem. May I add one thing here? I'm from, I'm from Mongolia. In my country also, we have a medication problem. We have just only Amiodarone and beta blockers who are curable and visceral. Presently, we added the Pilsen and Propafenone. We don't have other medication, but we still need the Sotolol and also the other medication. So I am here right now in the United States, in UCSF, California, and I tried to contact the medical, you know, medication companies like the flecainide. I tried to contact the free end, but still the manufacturer says it's a very small market. We cannot provide you this medication. If you want to buy, you have to buy more, buy more amount. So I have had also tried to bring to Mongolia, like isoproteinol for the, for the EP study. Yeah, we don't have. So I tried to contact the Japan and I am trying, what, the last three years, I am trying, but I cannot, I haven't respond yet. But I think- Go ahead, please. Yeah, so we have this problem, but here in the United States, you have every other medications and what you want and what the patient want is up to them. Here in Mongolia, we have a very different situation. Also contacting the medical industry is very difficult. The Mongolian government is telling, any company can, if they can bring the medication, they are open to have it, but still there is a medical big, like that kind of industry do not allow us to buy with this huge amount. We have just only 3 million. And based on the 3 million, it's like, for all Mongolian population, we have to buy medication, but this would be nonsense. Yeah, I think that that brings up an important issue that I think the barriers are different in each country. Right, and so that's the question here, so you come up with the sort of the wishlist and sort of what is the barriers that the government, is it the fact that the market is so small that no one wants to sort of put money, but then if we understand what the barriers are, then we can think of solutions. No different than, actually HRS has worked together with Michael Orloff and others from industry to put together devices to be able to go to Ukraine. Again, trying to go and figure out different ways to do this, because once you understand the barriers, then the logistics can be taken care of. So I just use that as an example that we can potentially, if we can then identify the individual barriers in each country, then I think that perhaps this is a problem that we could really work on and deliver a real change on. Yeah, right, no, this has been a great conversation. I mean, we've just kind of touched on a little bit of things. I think we could be talking for a really long time. I think that some of the comments that were made earlier is, again, getting a little bit back to the workforce problems about having people train in other countries and then coming back. It definitely seems that there are a lot of areas, Pakistan is one of them, where there's just few locations of sites where there are like physiologists, Indonesia also, and that perhaps we can come up with some plans in the future to kind of, all of us to kind of see what changes we can make and help with this. No, I think that that's right. So what are some other health policy issues that come up before we close and kind of figure out sort of what the deliverables are going to be out of this? Because if we're gonna have a summit like this, we get all these people together, people put work together, we need to have something sort of come out of this and of a sort of real sort of value. Are there any pressing issues from the health policy side that anyone that we haven't covered want to ask about or to talk about? And so I'll just go in order that I see here. So Amir, how about Pakistan? Well, we have a lot of issues. I've highlighted the drug issues also that affects training. The person training in cardiology or electrophysiology does not believe in. So if he cannot afford a device, a patient is denied medicines also. You're non-availability as well as lack of training. So I think that's a major crux. Thank you. And how about Thailand, Dr. Sirin? I think we are seeing the improving policy as one of us have to, the EP doctors sit in the government body. So I think that that's what we need to do. And we need to promote our field to the public as well. Social media, yeah, it's very, very, very strong influence. It's interesting thinking about the sort of what each country has that has a bigger strength that could potentially be leveraged. How about in Mongolia, Dr. Svetlana? Mongolia, our biggest problem is the doctors and also in teaching. So we just established our teaching laboratory in 2016 and we have a lot of challenges, but still we are trying to develop our association more. So we are trying to do more. And for public, we are doing like a safe awareness and also we did a few times a certain protective awareness day once a year. And the most biggest problem for us is now like training for doctors, nurses and technicians. Yeah, training at all levels, for sure. Isn't that the case? Not only for doctors, we also need the training for technicians and nurses. They are the most, how to say, they are the base to do the procedures. Yeah, so nurses is okay, but the technicians is definitely we need them like a 3D mapping technician. Without the 3D mapping technician, you can't go anywhere. Yeah, so you can't tell. So our biggest problem is that one and our government is, health insurance is by universal and the government is like 100% from the health insurance, but still they are giving a limit in the yield limit for the procedures. And we are trying to fit in that one. So local problems, we can solve by ourselves, but the international problems, we can't. So we are asking for support for the international problems, that's all. So true. Thank you. Otaru, how about Japan? With regard to the anti-rasmic drug, so even in Japan, we have a similar problem, such as kinadine or propranolol is difficult to prescribe because the genetic company does not produce such an old and cheap drug. So that's a problem. So recently we cannot prescribe kinadine in patients with Brugada syndrome who had a frequent history of VEF. Of course, their ICD is implanted, so their life is saved, but a very problem in Japan. And also regarding the workforce, in Japan, there are relatively a large number of electrophysiologists and cardiologists, but there still are not enough to do the many catheter abrasion and the device implantation. So recently, the young doctors do not be a cardiologist and electrophysiologist who is very busy and hard to work. So we need to educate such young people to be an electrophysiologist and cardiologist. And also, I think, I feel from this session, so we need to educate the foreigner young electrophysiologists to develop their arrhythmic area in each countries. Thank you. Thank you, Wataru. How about in Indonesia? We have all those problems as well, but now we are in approach to with the orientation and lobbying with the Indonesian Ministry of Health. And we are now coming to some sort of agreement with what they ask of us, the Indonesian Heart Association and Indonesian Heart Freedom Societies, because of the distribution of the cardiologists and the electrophysiologists, which is very, very uneven, because we are a lot of islands. So we need, of course, training, more training. I don't know if maybe HRS, any HRS can assist us with more young EPs who can get more training. In Indonesia, we have only one center where we can train who is accredited and train for electrophysiology. And that's not enough for the population. So training and training and training would be something that we really need in Indonesia. Yeah, absolutely. I agree completely. So let's think about sort of what's going to come out of this discussion. Obviously, this session is going to be recorded. It will be on HRS 365. It'll be available for posterity so that people can look at this and refer and think about it. As I mentioned earlier, there's going to be, the plan is going to be a manuscript that comes out of this with appendices that I can already imagine what it's going to look like, of tables that then compile things together with regards to issues with different countries, prevalences of disease, workforce, other types of things. Then that can be a resource that can be valuable for people sort of going forward. With that, we can then identify sort of, obviously, some countries are a little bit more advanced than others in this region with regards to having these technologies, et cetera. Can we then try to leverage those differences to provide training, to provide things like this? And I love the idea of thinking about medications because I think that that clearly is valuable. And that's where this interaction comes through. And I actually think that the biggest value out of this is that we've all met each other, right? Isn't that wonderful? Because this hopefully is not going to be a one-off. We've met each other, we've kind of seen each other on Zoom or sort of in-person with Vicky and I who met today. And now these relationships then can go on and go forward and develop even further so that as we all interact, there are so many different solutions that come from different places, whether it be Canada, whether it be in Texas or heaven forbid, Florida, et cetera, that in fact can then help. And there are always, you know, we are a global community that really does truly work together. And I think that this has emphasized this. So Wataru, I'll give you the last few words before we close. Yeah, so it's a nice session. So we discussed the clinical issues and our health policy issues in each country. So we learned a lot to improve the management of our resumes. Thank you very much. Yeah, and you know, thank you to APHRS and we'll work together. I think that this is what's really exciting about having this partnership together. And now having sort of met all of you as leaders of your respective countries in the field of electrophysiology and cardiology just in general, we've realized in fact that we kind of know this, that arrhythmia care is, you know, requires that entire group of people to think about hypertension, as Dickey brought up, heart failure, as was brought up earlier from our colleague in Myanmar. And so I think we have a lot of other plates to work on and really looking forward to this being the beginning of a long relationship. So thank you to all, both those of you who are here and also those of you who are watching online. Thank you.

health policy

cardiac arrhythmias

Asia-Pacific region

limited access to care

therapy availability

reimbursement issues

workforce shortages

public awareness

education

antiarrhythmic drugs

treatment options

healthcare resources

urban areas

rural regions

social media