Thank you very much, and welcome to this wonderful, wonderful African summit in Heart Rhythm 2024. This is the third year that we've actually done these kinds of summits, and they have grown, not only in stature, but in the number of people who have come. It's incredibly impressive, the number of countries that are represented here, and it's really incredible. It gives me incredible pleasure to be the very first speaker of this incredible session. So I'd like to, with no further ado, introduce Dr. Saad and Dr. Albumadi. They have planned a fantastic program, so thank you. I'm Eduardo Saad, currently the chair of the Global Relations Committee for HRS, and on behalf of the committee, it's a great pleasure to be here with you all today. I think this is a big day for the Africa Summit. We're all excited about it. It's a long program, so we need to be on time. We're going to have lots of five-minute presentations. So this is a major meeting. We're going to have over 25 speakers here from 11 countries in Africa. We're going to have over 150 people registered to watch online. So I think this is going to be a very long reach, and we have to make it as productive as possible. And also, I would encourage people to participate, to be as less formal as possible. So the idea here is to engage, to discuss, to bring out solutions, ideas, and to make this afternoon as productive as possible. So without further ado, I will ask my colleague, Dr. Felix Sogade, I hope I pronounced it right, from Nigeria, to take over, and we'll start our panelists and speakers. One other word for the speakers, they have requested that we try to speak close to the microphone so the sound is better for everyone in the room. Thank you. Bismillah ar-Rahman ar-Rahim. Dear colleagues, it's my honor and pleasure to represent Africa, the gold-black continent, with the energetic people, energetic doctors. And I would like to thank Dr. Judy and the committee of HRS to give us this golden chance, and also to the fellows who attended last year, Dr. Lahwani, who brought up this idea through this meeting. Introducing Afra to you, I want to tell you that we started in 2020 with our cardio rhythm in Kenya, organized by Dr. Gilan, and we chose Dr. Amy Bonny to be the president of this organization. Afra is a part of the PASCAR community, and this PASCAR is the Pan-African Society of Cardiology, and this is the statistics which was done by Amy Bonny and other colleagues, which showed the use of electronic devices and intervention electrophysiological procedure in Africa between the years 2011 and 2016. And it showed that in sub-Sahara, the situation was not good. Only South Africa and Senegal had the EP service, while in North Africa, there were more access to intervention electrophysiology. There was no consistent access to invasive therapies like pacing or advanced pacing and catheter ablation in almost 30% of African countries. Pacemaker therapy was performed in only 74% of the African countries which were shared in this survey, and cardiac resynchronization therapy was performed in 51% only. Implantable cardioverter defibrillator was performed in 39% of them, and only by visiting teams. The dark green are the countries who have good service of pacing, and you can see the white is lacking this service. Cardiac pacing training in Africa also was started, and this survey which was done showed that this service could be done between different countries, mentors from North Africa going to East Africa and to West Africa, mentors from South Africa going up into the East and so forth, and that was the good solution to help one another. African Heart Rhythm Association structure started after this 2020, and this was established due to unmet needs in the management of cardiac arrhythmia in Africa, and then we had this association. We are intended to have all African countries with arrhythmia diagnosis and management helping people. The organization is an ex-co, and then we have the working groups, and we have the ambassadors, and we have the regional representative. Here is the structure of our association, like any association, but we were interested to have regional representation from all different regions of Africa, North, East, West, and South and Middle Africa. We established the working groups, and we gave them assignment to make survey and to do publications and to do education on the languages, of course, the local languages in different African countries. We also invited young fellows and young doctors to share their activities with us through being ambassadors, and we imitated the era of having this ambassador in our association. We are doing a lot of effort in education because we found that if you educate young doctors, then you can improve the service and you can raise the awareness. Our all courses are for free for all Africans, even non-Africans from all over the world. We started with a foundation course by Muzahir from England, who is Kenyan in origin, and then was followed by another course, and then basic pacing course, advanced pacing course. We give very good attention to the allied professional, and we give courses in three languages, Arabic, English, and French. Also, David Bradley is going to start his pediatric arrhythmia course very soon. We train fellows from Africa in African countries because this is easier for them to have the same culture and the language and the barrier of the visa and the restriction of European United States issuing visas. So we started to train African in African countries as much as we can, and we provide this service for free for them. We give them also settlement, but no pocket money. We also organize webinars with different societies, and also we are interested in joining research and surveys in all over societies of cardiology and electrophysiology. Benvictus is the last one we joined. We have a lot of publications. I know you are not public and you are not existing. So we are trying hard to have publication, and Dr. Alamy Alam is doing very good research on WPW all over Africa will be soon published. Here are the publications we have. The joint meeting, we had it continuously with the EHRA, and now we are here. After we had this idea last year, now we are here with you in the HRS. Thank you for giving us this opportunity. Thank you very much for giving us this opportunity to be here. As the president of AFRA just mentioned, for many people that don't know Africa, Africa is not a country. It's a vast, huge continent. Because sometimes when we go somewhere, when people are talking about Africa, you think that it's a small country. No, it is not. It's large. It's huge. My task was to present the challenges of Central Africa, what we see in Central Africa that is really very challenging as far as EP procedures are concerned. I'm having no disclosures. All of us know that since it was first performed in 1958, cardiac pacing has expanded exponentially with now nearly 1,000 implantations annually per million population in developed countries. Why the need of cardiac pacing is similar worldwide? Developing regions of the world lag significantly behind their developed counterparts in having reasonable access to this life-saving procedure. The goal is to report challenges faced in Central Africa. Central Africa is a sub-region of the African continent, as you see on the map, comprising various countries according to different definitions. Middle Africa and having many countries, 11 countries. But are we talking about really Central Africa, where they are having an economical partnership? Those countries are six, Cameroon, Central Africa, Republic, Chad, Equatorial Guinea, Gabon, and Republic of Congo. They are also members of the Economic and Monetary Community of Central Africa and share a common currency, the Central African CFA Franc. Let us start with Congo. You see how on the map where it's located, Congo, and the main resource there is petroleum extraction. And the oil sector is accounting for 65% of the GDP and 85% of government revenue. And the 92% of exports mean that they are having really much resources. Cameroon is the country from where I'm coming from, and it's having really a strategic position on the crossroads between West Africa and Central Africa. And it's having nearly 27 million people. We don't have much petroleum in Cameroon, but we are having other resources like gold, like cobalt, like many other things. We are having Chad. Chad, that is in the north part of Cameroon, and having a population of 16 million. And also, Chad is having much of petroleum. That is the main exportation that gives lives to the country. We are having next the Central African Republic. And the capital there by income is approximately $400 per year, and one of the lowest in the world. And so, unfortunately, having much resources like diamonds, ivory, and cobalt. Equatorial Guinea is also one of the countries of Central Africa. Having much petrol that is exporting, and one of the highest levels of wealth there, because the population is not so much with 1,468,000. As far as infrastructures and human resources are concerned, we see that in Chad, in Congo Republic, in Gabon, and in Guinea, we are having less than two centers where procedures can be performed. Meanwhile, in Cameroon, they are having five centers where private sector is mostly developed. About pacemaker implantations per million of population, we see that Central Africa is not really well represented. We see Cameroon on this study that was done by AFRA members, where Cameroon is really very low with 0.14 per million of people in the population. And the other countries of Central Africa are not represented, meaning that the condition is worse than there. And again, who pays? Who pays? This is the main problem in Central Africa. Who pays? Patients are paying, and if you are not paying, you will just die. Cameroon also is not well placed on this graph, with almost all people paying for their procedures. And the implantation rates. The implantation rates depend on who pays, where the government pays, where there are some private organizations that pay. The implantation rate is high. We can see Nigeria, we didn't have data, but in Cameroon, in Mali, in Uganda, in Benin, we see that the percentage of implantations have been reducing depending on who is paying and depending on the year. And about ICDs. In Cameroon, the population benefiting from ICDs is low, very, very low, if you are comparing to Mauritius and to South Africa. Definitely also because of the fact that everything the patient is paying. About EP studies and ablations. When this study was done, we didn't start with these procedures in Cameroon. There is a single private center in Cameroon, in Douala, performing EP studies and simple cases. In Central Africa, despite the tremendous process, we face many challenges. Challenge of infrastructure, challenge of human resources and financial. Thank you very much. I would like to thank the Heart Freedom Society and the Africa Heart Freedom Association for the opportunity to be part of the EP community. I would like to meet you all and I hope to do so next year. As a disclaimer, I'm a clinician and have no public health experience. So I would like to thank the staff at Rwanda's Ministry of Health for helping me put together this talk on building a sustainable health care model in Rwanda. Rwanda is a landlocked country located in East Africa. It has a young population of about 13.7 million. Most Rwandans live in rural areas, as only a third of the population live in Kigali, the capital city, and towns around the country. Rwanda is known for the mountain gorillas. Cycling is big in the country as well. So why is Rwanda's health care system worth paying attention to? Rwanda has one of the most efficient health care systems in Africa. Its GDP ranks 35th on the continent, yet ranks 9th by life expectancy. There have been remarkable improvements in health metrics over the last three decades. As an example, the life expectancy increased by 22 years over the last two decades. Rwanda is among the few African countries with near universal health coverage. About 90% of Rwandans are covered by a community-based health insurance scheme, ensuring access to health and access to health care. Ensuring access to health services across all the levels within the country. The health care system in Rwanda is built like a pyramid. At the base, we have basic health services that take care of 90% of the disease burden, and there is a goal to reach 95% by 2028. Patients who need more advanced care are referred to the nearest suitable health facility. Now let's go through the different levels in the pyramid. Starting from the bottom, at the base, we have 60,000 community health workers who focus on preventive measures such as promoting healthy behavior in the community, immunization, sanitation, malaria prevention, and so on. The next level comprises about 1,200 health posts. These have rapid tests and can administer treatment for common conditions such as malaria and pneumonia. On the next level, we have 506 health centers that have basic laboratory tests and treatment. They have hospitalization capacity and they can deliver babies and so on. One more step up, we have 34 district hospitals. These have more advanced labs and equipment. They can, for example, do ECG, ultrasound, and X-ray. They also have operating theatres. In these hospitals, patients are mainly looked after by general practitioners with the support of a few specialists. The second last group comprises of three provincial hospitals and nine level two teaching hospitals. These ones have more specialists and equipment and can host medical trainees. At the summit of the pyramid, there are six referral and teaching hospitals which offer more specialized and sub-specialized services, and they host residents and fellows. Like any other health care system, especially in the low-income setting, Rwanda's system has many challenges. One of the pressing public health challenges facing developing countries is the double burden of communicable and non-communicable diseases. Similar to other low- and middle-income countries, Rwanda faces an increase of mortality related to NCDs. Another pressing challenge is the low density of health care workers. To achieve the third United Nations Sustainable Development Goals, Rwanda needs to quadruple its health care workforce to reach 4.5 health care workers per 1,000 population before 2028. Using myself as an example, I would like to paint a picture of what it would take to become a clinical electrophysiologist in Rwanda. Until recently, there was only one medical school in Rwanda that could only take about 100 medical students per year. When I joined it, it was and still is a very competitive process. After medical school, one must work for about two years as a general practitioner in a district hospital before joining a residency program, which I did. Until two years ago, there was no fellowship training in the country, so I had to go to Kenya for my three-year clinical cardiology training. Currently, there is no electrophysiology service in Rwanda, let alone a training program. To train as a clinical electrophysiologist in the near future, I will probably have to go outside Africa for two years, provided that I am accepted in a training program. To bridge the health care workforce gap, Rwanda has set an ambitious target to train 33,000 healthcare workers by 2028, including 900 specialists. To achieve this, there must be monetary and non-monetary incentives to ensure that current healthcare workers and new graduates attend in the country, strengthen and expand the community health service program to treat more patients at the community level. To complete the ongoing construction of Kigali Health City, which is an integrated system of health facilities with a goal to provide sub-socialized care within the country and attract patients from the continent at large. Finally, to ensure timely and cost-effective acquisition of equipment, medicines and technology. There also have to be the modernization of emergency medical services by improving timely response and coordination across the country. The numbers from the Rwanda's Ministry of Health show that the largest share of the budget is allocated to hiring faculty and supporting student enrollment. The projected outcomes of bridging the healthcare workforce gap are, among others, to increase the life expectancy to 8 years by 2035 and 90 years by 2050. It also includes prevention of 41% of NCDs related mortality. As a take-home message, to build a sustainable healthcare system, Rwanda is empowering local communities to treat most conditions. It is ensuring universal health coverage and plans to train and retain healthcare providers. Thank you. Good afternoon. Thank you for the introduction. So I'm going to take you through the challenges of EP in Tanzania. The sub-Saharan countries, Tanzania being among, we find there is an increase in the burden of lithium-ion. However, the delivery of EP services in the sub-Sahara, in Tanzania particularly, actually it is stagnant. So in Tanzania, we started EP program in 2019. This was basically the visiting teams. And the first case was done independently by the local team in 2022. That is three years later. So basically what we are seeing here, all cases initial, were done by the visiting team. And three years, we see now the numbers that are done by the local team are increasing. But there are numbers of barriers that makes the progress of EP in Tanzania to be stagnant. One of the factors is that majority of physicians are unable to either diagnose the arrhythmia, and also they don't know how to prevent it. So we created this WhatsApp group. Any physician who meets with difficulties could post through that WhatsApp. Then we can assist in interpretation, even plan the way forward. And sometimes if all we fail, then we can seek international consultation through other WhatsApp groups. Money power is also a very big challenge in Tanzania. We have three physicians who actually attended the African Heart Leading Society EP Foundation course. Among the three, only one candidate was able to further on training, especially hands-on training. So you can find the major limitation in the sub-Saharan, in Tanzania particularly, is the lack of training EP colleges. And the other limitation actually is the political will from the government. You will find there is very little support. In Tanzania, actually less than 30% of the population is insured. You will find less than 1% among the insured population is approved to undergo electrophysiology procedure, which means that the majority have to pay from the pocket. Now you will note that a single ablation will cost up to USD 8,000, which means it is six times on average. And the GDP per capita of the country, which means that the majority are unable to finance these procedures. So among those patients who underwent the EP study and ablation, 20% they were exempted and they were putting a lot of pressure to the hospital. There is also high cost of consumables as you compare with the purchasing power of the country. So when you get a patient with the arrhythmia, the first thing you consider is actually to approach by conventional ablation or mapping, which means that you are increasing the risk of radiation to the staff and to the patient per se. And this is actually as compared to actual to zero flow when it is done that we consider this a reducing amount of radiation. And this is what we see, the first zero flow that was done, assisted by Professor Satchit, and it was mapped by Stukato, both from Daktaria, Africa. But this cannot be done legally in Tanzania because we don't have a 3D mapping engineer in Tanzania. So because of the high cost of consumables, it means it mandates us to adopt and use protocol, which means sterilize and use a catheter. And here you are seeing this case that will use a catheter, and this was the serious catheter that got ruptured in the right atrium, and it was posing a therapeutic retrieval. And actually this is the case that we published here. And the key finding of this paper was that low and middle income countries face not only the critical cost of EP services in the sub-Saharan in Tanzania, but also the high cost of consumables subject them to reuse protocol. That causes complications like fragmentation that is important in this case. In aggregate, we target at least 50 percent of the cases should be done by local teams starting next year. In Tanzania, we have started our own society called Device and Arrhythmia Software of Tanzania, this having almost 16 members who are active as of now. And this carries a vision to see Tanzania becoming the center for excellence in the provision of EP services and also becoming a peripheral center for sub-Saharan regions starting next year. So this is how we started our training. This was two months training in Shandong, China. Here you can find Professor Mavet who supported us for two months covering all the costs and actually exposed us to a lot of cases. And also the great job that has been done by Medical Africa, here is Dr. Singh, he's come from Medical Africa, which is a non-profitable NGO based in the U.S. It carries a mission to advance medical expertise and care in sub-Saharan Africa through the training for the model, which means you need to improve health care and medical autonomy by investing knowledge, skills, and time rather than just injecting money into the health system. So in conclusion, the increased burden for arrhythmia is not being sufficiently addressed in the low- and middle-income countries. There is no legislation in the Tanzanian sub-Saharan countries that can help to calculate the incidence prevalence of arrhythmia. Therefore, this is posing a great challenge to implement the guideline-directed management of arrhythmia because of the existing barriers. So it is our recommendation that cost-effective strategies should be used at national levels to overcome all barriers and limitations of EP in these countries. Thank you. All right. Good afternoon. Thank you very much for inviting me for this program. And I'm very honored. Actually, I just joined the society, and I will pay my due soon. As you can see, I am not an EP person. And in Ghana, it's talking about training cardiologists. It's not talking about training EP persons. So presupposes that we don't have EP in Ghana. So I'm very grateful to my wife for allowing me to go to Ghana to experiment what I did for eight years. Otherwise, we would have been divorced and long gone. So Ghana is almost the size of Pennsylvania, and we have about 32 million people, about. And it is located in West Africa, obviously. It's 10 hours from New York, 10 hours from Washington. And we are right here in the convention center here, and Ghana is located there. So the cardiovascular disease in Ghana is increasing. It's increasing just like any other country, and it's worse in sub-Saharan Africa. So there's this talk about the double burden of diseases. So we have a system in Africa that did not allow training and empowerment of physicians. The Ministry of Health led to the training deficiencies, and subsequently, there's an exodus of doctors from Africa, especially Ghana, Nigeria, and other places. So the story is that in 2013, I picked my bag and went back to Ghana. And in 2014, I started training literally across the country. And we're only nine cardiologists in Ghana then. By 2024, I'm proud to say we have 32 cardiologists, which is still a small number. But for 32 cardiologists in that span of 10 years, that was a good achievement in my view. And there are 12 to 15 trainees currently undergoing training. So by the cardiovascular team, it's not just made of cardiologists. We have cardiac surgeons who treat patients. And actually, they treat them for a long time. When you refer a patient for bypass surgery, they keep the patient. They don't return the patient to you. And they keep the patient for a long time with LDLs running in the form of five, and there is no monitoring. But they do a great job. So there are nine cardiac surgeons in Accra. In Accra, we have 19 cardiologists with 12 trainees. When the number is increasing, what happened was initially with the previous training systems, we had single digits until there was improvement in the training capabilities. And so when I got there in 2014, literally, there was advertisement. I want to train. I want to train. I literally went from hospital to hospital campaigning. Then when I joined the faculty, there was a surge of trainees. And so the numbers obviously increased. This is not, I'm not saying I accounted for that, but there were other factors that led to the surge in trainees. And as you can see, from seven single digits residents internal medicine, we increased them to 25. And unfortunately, 2020, my wife and children had to move back to America. So I had to follow them with my bag again. And although the number is still there, we still need to have a lot of things. What did it take to get to Ghana? Several trips. It came at a very high cost. I left my job. Fortunately, my wife came with me multiple visits. I went to India, Bangladesh to see how they practice cardiology in those countries. And finally, after staying in Ghana for three years, in the Ministry of Health, the medical school decided to give an opportunity to train cardiologists residents. So it is, training is not new. It's been there for a long time in West Africa. The Colonial Masters United Kingdom started training. Our first president made a move to train specialists across the countries. And two of them are currently in the country, Professor Podunu and Lord Jader. These were sent out to train and to come back. But unfortunately, when they came back, he was out of office and they were not accepted easily into the system. So all their skills were left to district hospitals, which was unfortunate. But you have the West Africa College of Surgeons, West Africa College of Physicians. And then on top of this, we have the Ghana Medical and Dental Council involved in certifying doctors. So currently, there's a lot of increase in number of people wanting to train in Ghana. How do you get to become a cardiologist in Ghana? First, you have a medical school certificate. And then there's a loose, very complex system where you can run away at any time. You can leave the country after medical school, or you can decide to go for a certificate. Two years of training, and then you're done. I think my slides are almost done. They cut me off because I'm talking too much, but it's five minutes. So thank you very much, ladies and gentlemen. If there are any questions, please feel free to tell me about it later. Thank you. All right. We're back online. So thank you, everyone. My name is Ijeoma Ikero. I'm actually a cardiac electrophysiologist out of Houston. But my experience with setting up EP labs in resource poor countries is actually through a foundation, which the president of the foundation calls the Collection of Cardiology Friends who go to resource poor countries to help people. And so it's called the Cardiovascular Education Foundation. We've been around for a little bit more than 10 years. And most recently, we have joined with a collaborative where we are dedicated to providing cardiovascular education, care, and invasive procedures to a lot of countries in sub-Saharan Africa. I'm going to speak specifically about setting up EP labs in resource limited settings. And I have a little bit of a disclosure, but nothing really pertaining to this talk. So when you're setting up an EP lab, this is what you think about when you want to do it. You want your fancy TV. You want your ice catheter. If you can have 3D mapping, actually, that is compulsory, right? And then also all the tools that you would need. Well, in a resource poor country, this is not really possible, right? Because each of these, if you had to cost the process of a specific ablation, let's say an SVT ablation in the United States, and I'll quote the United States because those are the numbers that I know, we're talking about $8,000 to $9,000 for when you're talking about disposables, you're talking about the catheters, and then even more when you even account for lab time, right? So if we can get this, that would be great. And of course, a lot of labs, this is basically what you expect to see. You expect to see computers, you see the 3D mapping systems, but that is not what you are able to get in a resource poor country. And so what becomes the most important thing is trying to pare it down to the basics. What are the necessities of what you need? So with the Cardiovascular Education Foundation, we've been able to take a look at all of this and figure out how we can do it in a way that is cheaper, in a way that is sustainable, and in a way that we can probably hopefully teach other centers to be able to set up not just EP labs, but cath labs all over Sub-Saharan Africa. So if you had to look at your necessities, what do you need? You need personnel, right? Physicians. You need people who are trained and people who want to be trained. We've talked about the different ways that you can become cardiologists. It's not the same in every country. But if you can find a cardiologist who has gotten to the limits of their degree, and they are interested in training to do further training in invasive cardiovascular techniques, then they do have to spend a lot of time, a lot of dedication, probably going to different countries to be able to get invasive training. So you definitely do need local cardiologists who are willing to make that sacrifice. After they do that training, then you also need physicians who are able to proctor them, right? Because most of the time where you're going, they do not have these systems set up. So the way that we think about it here, your invasive cardiology training does not start once you start cardiology fellowship. It doesn't even start when you start your invasive cardiology fellowship. But if you think about it, your training in invasive procedures actually starts when you are a medical student, when you get exposed to scrubbing in and having a sterile field, you know, as a medical student in the surgery field, right? And then you have to do central lines as a resident. All of that, you know, your comfort level with that guides you through until you become a cardiac electrophysiologist or a cardiac interventional cardiologist. And that's the reason why you're able to do things easier when you get there and only takes one year for you, one to two years for you to train. Well, when we're talking about the personnel in these resource poor countries, a lot of times they don't have access to all the things that we have access to. So sometimes when you see them, actually their first exposure to invasive techniques is actually either in their training when they go outside of the country or sometimes in your lab. So you have to have that mindset when you come in. The second thing that we also have to have is EP technologists as well. A lot of things they learn, they learn in theory, they have not also seen it in practice. So basically you need people who are willing to learn and go through the steep learning curve. You also need folks who are willing to teach and it takes a lot to teach and a lot to learn. So those are the two things. The second thing that you'd need, of course, is equipment. There's a fixed equipment, so you need your recording system. You definitely need an RF generator. There's some folks who have said cryo, but costs demand. And then if you can get an irrigation pump, that's great. In our experience, we've had very generous local hospitals who have donated products for us. And so we have been able to do that. And then disposables are key. So if you can buy them, that's great. But most of the time you get very adept in, you know, re-sterilization, which we talked about and also creative ways of actually reusing catheters, reusing cables. And definitely we talked about the patients. So the patients are there. You have to know how to diagnose them. You have to know how to identify them and what does that mean? You also have to teach your referring physicians exactly what they're looking for so that you can treat the patients. So what have we learned over our 10-year period of doing both EP and invasive cardiology or interventional cardiology? Well, education is key. You need invasive cardiologists. You need to educate your referring physicians. Local buy-in is a must. So we have to talk to government. We have to change healthcare policy because we've talked about costs. We've talked about how expensive this is. The price per capita for each patient is so low that a cost for a procedure, if they had to pay for it themselves, is exorbitant for a patient. I started getting really involved in electrophysiology in the developing world when I talked to actually a family member of mine who was having palpitations. And I was talking to her and all of a sudden she stopped talking. She started crying. And I was like, why are you crying? Like, what's going on? And of course I was really worried about her. All of a sudden she stopped and she said, okay, everything is fine. And when I asked her what was going on, she said, well, I think I'm going to die, right? And she's really upset. Come to find out in talking a little bit more, she actually had palpitations and she probably had SVT. I didn't have an EKG on her, but basically by the time she was, you know, freaking out, breathing in, she balsalved and she broke her SVT episode. But when I told her that, hey, this is something that can actually be treated, she was astounded because she had gone to doctors, doctors had told her, you know what, you need to calm down. It's okay. Don't get too worried. You know, you're a little bit hysterical. And so she was really thinking that her mind was playing tricks on her. And this is the story for a lot of patients across the board. Not only in Nigeria, of course, but in all over the world, in the United States, we can take care of them, in Europe, in other countries that have resources, we can, but in countries that don't have that, those resources and don't have that knowledge, we haven't been able to. And so by doing this, by explaining to folks, hey, this is not just, even though it's not life-saving, patients are not necessarily dying from it, it definitely improves and increases your quality of life. And it is something that can help your populace at large. So talking to government, talking to those who are involved in health policy, explaining to them that there has to be infrastructural change, that is definitely something that needs to be done. And that is all I have. So if you can visit us on our website, cvefonline.org, if you're interested in donating, interested in volunteering, donating either your time or your money, we'll take both, we would be happy to have you. Thank you so much. Dear colleagues, dear chairpersons, it's my great honor and pleasure to be with you today with this brief review on building a comprehensive and structured EP education in Africa. I'm Dr. Hani Samir from Egypt. The status of cardiac electrophysiology in Africa has been elegantly described by Muzahir Etel in their paper published in 2021 in JAK, detailing the ongoing efforts and future directions to step forward the health risk management in Africa, where experienced electrophysiologists are concentrated mainly in North and South of Africa and vast areas within limited access to any EP service or served by infrequent visiting teams. One of the main challenges is a shortage of trained personnel. The authors proposed a roadmap for tackling this problem through the creation of educational working groups within the Africa Heart Rhythm Association, adopting innovative teaching tools and resources, as well as the establishment of fellowship grants in EP Center of Excellence. This is how we reorganize the AFRA structure with the executive core working with multiple educational working groups to prepare high quality comprehensive programs. Each African region is represented by a regional representative that works close with AFRA country representatives in their region in order to disseminate awareness of these educational courses and encourage candidates' engagement in the AFRA activities. 15 educational working groups have been created covering the whole range of heart rhythm management. We started with mini-crush courses provided online through an educated educational platform, as well as year-long structured comprehensive courses from basic knowledge to advanced EP management. Examples are the EP Foundation course, the AFRA Cardiac Pacing Certification course, certification courses dedicated for EP allied professionals, nurses, and technicians as important cornerstone in the EP team. Provided also pediatric and congenital EP management courses. Together with the organization of multiple onsite sessions during major African scientific events across the year. Let me go through the analysis of one of the online courses, the Basic Pacing Crush course, with more than 300 attendees from over 25 countries with the participation of EP fellows, senior consultants with different levels of experience and as you can see with an encouraging level of satisfaction by the innovative online education and the quality of the received knowledge. To summarize this educational effort, let's see the year 2024 in numbers till today. We are having six structured courses for the year 2024 presented in three different languages, English, French, and Arabic. And 1,200 regular attendees reached from 32 countries with the provision of more than 300 CME hours and planned for end of courses online testing and evaluation. After the theoretical knowledge, selected candidates will get six month to 12 months onsite training in certified high volume EP centers in Africa and outside to enrich their skills and get back to provide appropriate EP service in their country of origin. Again, thank you very much until we meet in person next year. Thank you. Good, hello. So my name is Zenichi Hara from Abbott. So dear chairs of the summit, thank you very much for the invitation. I'm happy to represent Abbott and talk about how we can bring EP and develop it in the African countries. It is a very good timing to talk about this here because when we take the public health perspective, many African countries in Sub-Saharan African countries together with the other developing countries, I mean, economically developing countries are shifting a profile of disease as well. So we see downwards trends in infectious diseases and uprise in cardiovascular diseases. And we know that those NCDs, so non-communicable diseases are chronic. They cost a lot, they're a high burden in the society and the society and the health system needs to adapt their infrastructure and also the environment to treat those. One way to look at it at first would be to look at the number of hospitals and the number of physicians. We can, of course, always debate what is the optimal number of hospitals, but starting from a very low, oh, sorry, starting from very low, it would be good to have a higher number. And when you see many of the Sub-Saharan African countries are still low in both. So this is an environmental challenge that we also need to tackle together. And this is kind of the base. Now, looking at EP procedures, it is an advanced procedure. So on top of that, there are other factors that we need to consider. It has been already presented and talked repeatedly by our colleagues and friends. The first one, of course, the most important things are people. So we need a team, the physicians, the nurses, the whole team, and we need education. This has also been brought up. We need centers in order to have a local representation of the expertise. The other one, when we talk about products, be it implantables or catheters or capital equipment, we need to have it registered in the countries. And this is something that we usually don't think, but it is also a burden or a time-consuming process. And if you look at the US here or Europe, you have CIMARC, we have those standardized regulatory process. So if you can accept that and translate it in the local countries, it becomes swifter, it becomes easier. When you require local registration on top, this adds more time, effort, resources. So those are the things that we also need to look into. We also need to look at how to identify the patients and put them into the treatment pathway. So we know they are there, but how do we diagnose them? How do we bring from non-diagnosed to diagnosed to specialists, and also in the end, having them treated? Finally, also many of our colleagues who are talking about it, it is funding. So we need to have proper reimbursement funding of the procedures, of the devices, of the care. And it is true that those are costly, but as we said at the beginning, those chronic cardiac diseases are very costly to the societies as well. So here we need to talk with the local payers and the funds that it is not necessarily a cost that they need to incur, but more like an investment to get the patients better and therefore bring them back to a social workforce, social productivity, the economic language that we need to speak with the payers. And we should definitely move away from this out-of-pocket that we saw earlier on, because it's true, it is not a sustainable modality if we think about a bigger mass of patients to treat. So finally, from the industry perspective and from us Abbott, we can help in those category of themes. So we do have our reach, our footprint in the other countries, the US, Asia, Europe. We are happy to, of course, work with you to translate those into the other countries and the regions, sorry. Work on the therapy development. This is really connecting the expertise, the teams together so that we can learn each other and how to bring those therapies and care into the local countries. And then we also have certain experience that we can potentially share with those registration approval. And very importantly, we would be happy to also go talk to your local payers and governments when it comes to what is needed to have a proper funding, what is the reimbursement that is required and all the infrastructure that goes together. So let me conclude that we would be very happy to work together to bring those EP into the African countries. Thank you very much. Oh, all the panelists come to the table. Those were very interesting presentations and caught my attention. I mean, the discrepancy between this last presentation and what is in the reality that we've seen, that's actually what is very, to me, very interesting and something that I've been thinking about a long time is that facing that reality that we've seen, some sort of highly technological solution on the one hand seems like science fiction, but on the other hand might be what actually is needed to provide a high level of care without having to deal with each and every country, each and every place. So that for me is fascinating. So I don't know if we can expand a little bit more how easy it is to implement this type of system. So the patient is brought to the truck and operated on the truck. So the concept, I think that you're right. It is on the one hand, it feels very strange to have such a high tech kind of offering when there's very little service available at all. I do think about it very much like the model where across Africa, across India, cell phones became ubiquitous before there were any landlines. And so you do have sometimes in life, in society, that type of ability to leap forward with technology that enables things in a different fashion. I think this could be similar. The model would be establishing, let's start with one truck like this, and then you could park it, let's say in the parking lot of a hospital, stay there for a few weeks as kind of patients have a mask. You would obviously need, there are other aspects of this that would have to be worked on, like people who would start to focus on the next city in front, making sure that patients are lined up, that there's kind of sufficient awareness among the cardiologists that they should kind of bring patients there. But then you'd be able to move the truck to the next hospital. You would use the local supplies from the hospital, saline, blood, everything else, you could use kind of the local supplies, you could use local physicians who have just general interventional skill for access, to gain access, to take care of the patient, but really leverage EPs from around the world to actually make it work. I wanted to support that idea because in Cameroon in the past, there was something called a mercy ship. There was a ship coming from Switzerland and coming with many specialists and performing almost all types of surgeries. And it works well. It works well before the bus will come or before the truck will come. Advertisement will be done in the country, in the cities. And when it reaches, those patients are just programmed and it works and it works very well. The idea is quite fascinating and seems really to work. So let's encourage participation of the audience. Please go ahead. Thank you. Thank you for having me. This mic is on. I think it's on. Just, if you had to speak near, yeah, just close to the mic. Okay. So Sam Omotori from Cleveland Clinic. Thanks for such excellent presentation, everyone. My question is directed to Mr. Official of Serotaxis. We are quite familiar with the technology. I use it as a fellow. I used an IOB2 as a fellow at Cleveland Clinic a few years ago. My two questions. So how far away of remoteness will the operator have to be to be able to implement such a remote navigation? And secondly, is it currently catheter agnostic or does it have to be Serotaxis remote catheter? Thank you. Perfect questions. So first we've advanced the technology a lot from the days of the NIOBI at the Cleveland Clinic. That's where, you know, this newest robot that I showed you is able to fit very easily without construction or using normal power. So that's been, those are some of the enabling innovations that make this vision possible. In terms of remoteness, every robotic procedure is performed remotely, but typically from a few meters away from the control room. We have now seen dozens upon dozens of cases where a physician might be 10 kilometers away from their house or from, you know, a different hospital close by. We've seen a few cases, very long distance. So between the U.S. and China, between China and Russia, between the Middle East and Europe, between U.S. and Europe. And so there've been several of these cases. I actually see Professor Pekka Rakuten and just walked into the back. He performed one from Dubai to Helsinki several years ago. So that definitely works without latency and kind of, it works very, very well. On your last question about the catheters, a catheter that is driven by our robot has to be a specific catheter that has magnets in the distal portion because it is really steered from the distal tip. That's our mechanism of action. And so it does have to be a specific robotically steered catheter. We have the one obviously that's been used to date is the Thermocol RMT catheter. And we've also just filed earlier this year for CE Mark and FDA approval for a next generation catheter called Magic. And so hopefully by the time a project like this would take place, we'd have that catheter available as well. Just as a reminder, I think right here in Boston during HRS in 2006, if I'm not mistaken, there was an AFib case where the patient was in Milan and the operator was here in Boston. I think that was the first time that was the procedure that was performed across the Atlantic. And that required major internet infrastructure, everything right now from, well, for my phone, I can see a lab in our office and I can see everything and communicate it with it. But from any computer with normal browser, I could control a robotic system around the world. Enrico. Thank you. Thanks for a great presentations. My name is Enrico Ferra. I'm an EP fellow here at Beth Israel in Boston. My question was for Dr. Ihara, but we'd love to have a perspective of the other panelists on their country level situations. In 2020, I worked with WHO to build the list of essential medical devices for cardiovascular care. And so EP certainly is very heavy on devices. And today we talked a lot about capacity building in terms of having physicians and other healthcare providers but we found a big barrier is having the technical support from the life cycle of devices. So storage, maintenance, troubleshooting and any sort of necessary often onsite support. So I'm wondering what has been available so far? What is a workforce representation for life cycle support from your perspective, but again, at different country levels, not just healthcare providers. Thank you. No, thank you for the question. So definitely from an industry perspective, the life cycle management and also, I mean, all the supply chain, this is something that we need to focus on heavily. So it really has to be with finding a local place or local people, local collaborators. It may or may not be our own company people could be like a third party companies. It could be also support. So those are kind of the network of expertise and firms that we are working together. And then really when it comes to local facilities and if place is lacking at the hospital, this is definitely something that we need to work on depending on the capacity and also looking at how the, for example, the procedure volume and realistically looking at the throughput, we would definitely like to adapt. Yes, so I think for Ghana, the scenario is such a way that it's a multifaceted problem. And one of the things I noticed in training the cardiologist was lack of middle level personnel, nurses and technicians who knew what was going on in the lab. So I was putting pacemakers, but nobody else in the room knew where I was, what I was doing. And when it came to interventional cardiology, it was really, you're just alone in the desert. So I think we, part of this system, we have to really include the middle level, the part of non-medical staff in the equation. Otherwise you would train the EP person without the support system, you're nowhere. I think we need to work on that. Exactly, so I think it's really, as I also said, it's the whole team, definitely. So we need to have like the ground people as well together. And also to my colleague that was talking about it, when we need support remotely, those in the internet times, we can, theoretically can be anywhere and also support the cases. And maneuvering a catheter is one thing, of course, which is of course great. And then to be able to see the screen and to be able to give indications how to do the procedures, that's also something that we can support as well. Please go ahead. Thank you very much. I'm Paula, I'm one of the EP fellows from Washio. I have a question directed to Dr. Akama. I'm really impressed by what you've done in Ghana. And I know Ghana is like the neighbor of Nigeria. I'm originally from Nigeria and I did some residency as well in Nigeria before I came to the United States. And my concern is just when you invest that much in training, whether mid-level physicians, and we know there's a huge, huge drive to migrate either to the US, to the UK, Australia, mostly to the Western societies. Are there any ways to kind of limit the migration? I mean, there are many reasons, multiple reasons why people migrate. Financial reasons is one of the strong factors and there are so many other reasons, but are there ways to kind of mitigate that just physician migration, middle level workers migration, nurses migration is also really a big thing. And secondly, for the stereo taxis as well as all the other devices, is there a way where we can have, just like the way when I was growing up in Nigeria, there used to be like a way where we don't make cars, but we assemble the cars. Is there a way to have like an assembly plant of some sort to kind of drive down the cost of some of this, this possible catheters that we don't necessarily need to reuse and have a complication like that shown with a broken CS catheter? Thank you. So thank you very much. So part of my presentation, which I didn't get to, was to talk about the exodus of doctors at different levels. It's a serious matter at this moment. And the pool system, there is a push system, which allows third world countries to push their doctors out of the country, but the pool system is becoming sophisticated. For instance, in Tennessee, where I practice, they have passed a law that starting July this year, they will take doctors who have experience in their country without training residency in America. And it is not in Tennessee alone, other states are joining in. So the pool system is very hefty. And so my challenge in Ghana right now, I have 10 brand new doctors, cardiologists, who are looking for something to do, EP, interventional cardiology. And there are limitations. One is limitations in terms of facilities, limitations in terms of frustrations from the system, limitations in terms of training. So they are just willing to do anything to go and train and come back. But even if they come back, the cost of cardiac catheterization. So for instance, when I was an attendant at the University of Ghana, my salary for a month could not pay for my cardiac catheterization. So if I was having a heart attack, I couldn't afford a cardiac catheterization. So that meant that we had to find a way first to decrease the cost of these procedures. We have to decrease the cost of the procedures to keep the physicians in town. Otherwise they can train and go back, but they can't practice because putting one pacemaker would take a whole lot of 10 family members to come together with their money. So even if you train them, they are likely to run away. So that is a big next step. Afra have to think about how to keep them. I have some ideas. One is to not castigate or have this misconception that we're running away from Africa, but to enable us go back and help. So the EP lady from, forgive me, I forgot your name. Your system is working very well, but if we can go back intermittently and help, but the government and the systems in Ghana or Africa and Nigeria do not even want you back there. They tell you, come back, come back. You get there the first day, everybody's vanished. Nobody's going to come and help you. And you'll be left alone in that cat lab. And if you're lucky to survive it and they don't thwart you, and I'm serious, they'll thwart your effort. And I've experienced it. So it is a very complex system, but the diaspora have to come together. Let's not be individualized. Let's get together and then go en masse and help the system because otherwise the exodus of doctors is going to continue. And we have residents who are leaving currently. I have two, a couple of residents who have just left Ghana for U.S. The cardiologists are also planning to leave. And it's the same thing across Africa. Please, Dr. Krohn, our past HRS president. Thank you for being here. Thank you, Eduardo. So Andrew Krohn, I'm from Vancouver. I'm the recent president of the Heart Rhythm Society. And I'm very heartened to see two years ago, we began with APHRS and last year with LARS and this year with Africa. And it's wonderful to see this come together. I have a fellow who's from Sudan and he's finished two years of EP training after five years of training in internal medicine and cardiology in Saudi. And he has abandoned his dream of bringing EP to his home country because his mother is more concerned about the ability to be awake tomorrow morning because of basic safety and nutrition. And so the prospect of the economic or infrastructure ability for him to practice his trade is something he's abandoned and this is tragic. So he's now seeking immigration status to see whether he could just find a job because he's got three kids and trying to survive now in Canada. And it strikes me that there's two parts to a potential goal in this situation. So one is ideally, I think, to try to figure out a way in which people like me who would like to volunteer, how I can help with both provision of care and teaching, including to the middle people and not just physicians, because quite frankly, this is a team sport. It doesn't help to have physician skills. You need everything. And the second is the long-term, which is the English analogy of give a man a fish and he eats for the day, which is provision versus teach a man to fish and he eats for life, which is education. So I guess as an individual, but also I think as Heart Rhythm Society, we would ask how can we as persons and as an organization support that education long game while we help as individuals in the moment to help you do the most you can. And so a pragmatic example would be refurbished, recycled, re-sterilized devices and create platforms to enable that. I did this in Pakistan about 10 years ago with a former trainee and at the time came with literally a suitcase of ICDs and pacemakers and told them it was, I sort of went under the radar with the import. But the point is all the ICDs were put in as pacemakers because that is the urgent demand. And I learned a lot there about the status of the people who I was helping to care for with my former fellow. And I think that voluntarism exists in most of us. And the question is how to harness it to teach you to fish. So I'll answer that question because I think that exactly what you said is really the motto that the Cardiovascular Education Foundation was founded on. And we say it all the time. If you give a man a fish, eats for a day, teach a man to fish, he'll eat for the rest of his life and his family will eat for the rest of his life. Or a woman, right? And so basically we understand that we as a group had a little impact, but by partnering with other organizations, like you said, there are a lot of people across the United States and across the world actually who have that same thought process that, oh, we've been given so much, how can we help? And they might not, there's some people who want to help intensively and there's some people who want to help maybe once a year, maybe once every couple of years, but they just need to know how they can help. And we have created a Cardiovascular Education Foundation Collaborative where we, and it's a WhatsApp group because WhatsApp is used all over the world, where we have electrophysiologists, physiologists, nurses, everybody who's involved with arrhythmia care and we let them know, hey, these are opportunities for you to help. We actually started a YouTube channel where we give lectures every week, actually twice a month now, where, and it's basically with the idea that, hey, we're also trying to educate the physicians who are in the local countries so they can understand and recognize how to educate or how to recognize these arrhythmias. And our whole process is like kind of a four-pronged approach, right? We're providing care to indigent patients. We are providing education to physicians. We want to provide a little bit more research and more data to let people know this is what is available. For instance, where can you get your device? Okay, you've gone to Italy, for instance, and you have an SICD and this actually happened, right? You have an SICD, you come back to Nigeria, where can you get your device interrogated? Like, what does it mean to get a device interrogated? We'll have that on the website. And so basically it's identifying all of this and what we do need now is support. So I'm glad that HRS is willing to help. And in reverse, AFRA is encouraged to create sort of a platform for voluntarism that connects all of those components because surely your organization can't fix it all, right? Thank you. Thank you. Well, thank you very much. We are running way behind schedule. If you want to just make one quick question, one quick answer so we can go for a five-minute break to come back. I know there's a lot going on and I don't want to break that chain, but if you can just do a quick question, a quick answer, please. Absolutely. Thank you. Good afternoon, everyone. Judith Atom, I'm with Biosense Webster and originally from Cameroon. So happy to see Cameroon here represented today. My question really is really around governmental policies, right? I can imagine we have a lot of NGOs and there's a lot of activity that's going on, but I can imagine a lot of the barriers in, you know, just like you mentioned, even someone volunteering their time to go back to the continent to help or an NGO trying to come in, trying to bring in devices and things like that. So I would love to hear a little bit more about the acute challenges and maybe how you're working with your local governments, because I would imagine that, or maybe even as a whole, you know, looking continent-wide, you know, maybe with WHO or some of these other organizations, but how, you know, what are some of those challenges that we're facing, even just trying to just bring devices in or people coming back to even try to help? So I would love to hear a little bit more about that. Well, in my case with our group, we've had to be a little bit creative. I mean, we have to know people in the government and we've reached out to the Nigerian, like most of the time we're doing our trips in Nigeria. So we've reached out to the Nigerian Cardiac Society. They have, you know, connections in government and we're able to bring devices in. Now, ablation is a little bit more complicated. And so that's a process that we're actively going through, but it's been a process that we've been talking about for at least the past 18 months. So we'll see how it goes, but you're correct. It's definitely more complicated than just, it's not something that you can do in Africa because every country is independent and it's on itself. And so you have to do it on a country by country basis. And there's so much need that it becomes a little bit like, you know, too many voices and trying to be the squeaky wheel. But I think that as long as you have continued pressure, then hopefully one day our voices will be heard. So, but we'll see. Yeah, and in Cameroon too, as you are coming from Cameroon, you know, the condition is really complicated. You should fight for everything. You should do the pressure to press, press, press, know for them to sign whichever paper that you need to import. And that's why the cost is so expensive and people cannot avoid. It's the main challenge. Government, it looks like the government is not interested at all with activities. Right, and the biggest challenge is the fact that the governments are not alert and oriented. They have a different perspective about health or they decide to be like an ostrich with the head under the sand. And it is a massive catastrophe. For instance, Professor Crawford reached out to me, his research project about explanted pacemakers. He wanted to use Ghana as one of the areas where we could be part of the research. The Ghana government refused. We don't want dead people's pacemakers, quote unquote. So there is that system that we need to, but I think AFRA has a platform now that we can leverage and start talking to governments. Because without the government's input and changes on the policies, you can't go anywhere. You can do whatever you want to do. If you get to Ghana and you don't have that support from the government, the hospital will not do anything for you. There are instances where people came to Ghana with all the equipment to help and they were turned away because the hospital said, we don't want you. The government says, no. So it's a huge problem. You don't have, and yet you don't want to be taught how to fish. So it's a very difficult problem. Well, thank you very much. We have a wonderful session and we're gonna have, take a five minute, really five minute break and then reconvene. Yes, I should have a disclosure. I'm the CEO of Stereo Texas. So thank you very much, Dr. Segura for inviting me. Thank you AFRICAN HRS. It's a pleasure to be here. This is a topic that is very close to my heart and very exciting. So I'm delighted to have the opportunity to share it. We've got a short amount of time, so I'll jump right in. In the coming slides, I'll share our concept to leverage advanced robotic technology and telerobotic presence to sustainably offer EP ablation therapy and develop local EP expertise in underserved regions of Africa. The problem is well understood and was discussed by many of the previous speakers. Access to EP services are nearly non-existent in the vast majority of Africa. Africa has over 1.3 billion individuals of which 50% are under the age of 25. If you look at epidemiology, even considering the youthful nature of the continent, over 10 million Africans are suffering from arrhythmias. But the number of EP labs in all of Africa is just about the same as in Massachusetts, this one little state. With a population half of 1% of the size of Africa. And the inequity of access and EP therapy is far worse with over 80% of countries not having any EP functioning labs at all. EP is a sophisticated specialty and building an ecosystem from nothing is very difficult. You need specialized expertise, devices that allow for safe therapy and the ability to establish sites in a cost-effective fashion where the clinical need is located. In reverse, you need the right facilities, the right devices and the right brains. Miss one of these three critical pillars and the others are insufficient. Our approach to bringing these together is an out-of-the-box approach, akin to how cell phones leapfrogged landlines across the continent a couple of decades ago. Our approach includes three key components. First, a mobile EP lab, one that can be cost-effectively leveraged and cover a wide region, traveling between areas with concentrated patient demand to ensure the lab is constantly utilized. Second, a robotic magnetic navigation system that has been extensively demonstrated to be particularly safe and effective in cardiac ablation procedures and can be operated tele-robotically by an EP thousands of miles away. Third, a network of experienced electrophysiologists from around the world who can operate the robot from the comfort of their home or office and provide their specialized EP expertise to the treatment of patients and the education of local medical staff. Stereotaxis's robotic technology is well-proven with 150,000 arrhythmia patients treated to date using our robotic systems. Clinical data from thousands of patients in hundreds of publications consistently shows that the soft, gentle magnetic ablation catheter is particularly safe and forgiving while allowing for millimeter precision with direct control of the catheter's distal tip. Our latest robotic system is mobile and can be housed in a typical semi-trailer. A robotic procedure is always performed from a remote console like you see there in the slides and advanced internet connectivity has made safe long-distance control without latency, something we have been able to demonstrate in dozens of procedures. In these two videos, you can see how a truck designed to carry a typical shipping container can accommodate such a lab with significant space for storing supplies and equipment. The local staff, which could be local physicians with sufficient skill to gain access and manage the patient but without the specific EP expertise would work by the patient and at the display console, all the equipment in the lab is powered by standard 220 volt power and so this is very much a viable solution. Remote EP physicians here in the States, in Europe or elsewhere, would be able to communicate with the lab and see and control all the disparate lab equipment using Stereotaxis' proprietary large integrated display. A standard satellite internet connection using something like SpaceX's Starlink would provide sufficient bandwidth for high quality, low latency telepresence. All of the technologies I've shown are real, fully developed and have demonstrated their performance and clinical value. The combination in this setting though is unique but it's very much viable. It would provide the most high-tech and clinically safe and effective care to African arrhythmia patients from an endless pool of talented global EPs who can share their expertise at any time without the challenges of travel and access. It would be highly cost-effective compared to building a fixed EP lab in a fixed location or continuing to fly EPs from around the world to Africa. Our estimate is that a fully equipped mobile EP lab could be established for less than $2 million. With access to EPs in every time zone, it could be active 24 seven and easily treat a couple thousand patients a year leading to a fixed cost per ablation procedure of less than $1,000. Most importantly, it would serve a valuable and critical role in expanding high quality EP care to many underserved patients. We hope to be able to work to make this a reality and if there's any interested parties or partners that would like to work with us, please let us know. With the first successful demonstration of a mobile EP lab, the model would be highly scalable and could be replicated and deployed cost-effectively across Africa and much of the developing world. And thank you very much for the time. Good afternoon. I would like to start by thanking the session organizers for the very kind invitation to be here. I also wanna make sure that I point out how momentous of an occasion this is because this is the first HRS Afro Summit. This has been a dream for a very long time and I really just want to acknowledge and thank everyone involved in making today a reality on really achieving this milestone. The title of my talk is A Low-Cost Solution to Reduce Sudden Death in Africa. And the idea is to introduce sympathectomy, cardiac sympathectomy, which is a cardiac neuromodulation as a form of anti-arrhythmic therapy with the idea of being provocative. With that said, here are my disclosures as well as my funding sources and an acknowledgement of my colleagues and collaborators at UCLA. This audience needs no introduction to the fact that cardiovascular disease is a major burden, not just in the so-called developed nations, but also in developing nations, which obviously have emerged from infectious disease era, but importantly, I thought I would frame my talk today with a clinical case, which is that of a male, 53-year-old male with non-ischemic cardiomyopathy and monomorphic VT who was sent to UCLA. And you can see here to orient you to this graph, the Y-axis is severity of VT, essentially number of shots per day, and the X-axis is day. And you can see we did everything contemporary for this patient, VT ablation, drugs, thoracic epidural anesthesia, et cetera. And it wasn't until we instituted neuromodulation in the form of the sympathectomy that the patient had complete arrhythmia suppression. And here's the first six patients we did this on. So to kind of bring that patient in the Western context to the African context, this very nice report from many of our colleagues in AFRA encapsulates my point very clearly. Two important points. First, if you look at the number of ICDs, at least the rate of centers performing ICDs per million patients as of 2013, not that much better today, you can see that that's drastically low. In my center in Los Angeles, per million patients, that number would probably be a hundredfold. The other is if when you look at this map here, you can see here that when you look at centers that are doing pacers and ICDs reflected in green, you see that there are few, but not that much. And really just to make the point that there's a lot of variability in Africa. And I understand it's a very big place, but at the same time, there is a lot that needs to be done because the need really eclipses the capacity. And so this is where I'd like to introduce the concept of cardiac sympathetic denervation. The heart is very densely innervated. If you look at this video captured by my colleague, Peter Hanna, you can see that in just this small piece of heart you see here, it is richly innervated with nerves. In addition to that, there are a lot of neurons that sit within the intrinsic cardiac network that are within the fat pads of the heart. And together, they regulate the heart in health and in disease. And I'd like to basically remind everyone that all of the drugs that we use for following cardiac injury, known as hemocardial myopathy, moderately reduced ejection fraction, are all drugs that actually address the neurohormonal remodeling. They address the nervous system, the sympathetic nervous system in particular. And what I'd like to do is just really summarize very quickly that when the heart gets injured, as shown here, myocardial infarctional heart failure, there is a profound degree of remodeling that happens within a nervous system that then feeds back to the heart and progressively drives arrhythmias and a heart failure as well. And if we could interrupt this with sympathectomy, that could be a low-cost solution for Africa. I'll even point out this slide here where if you look at a large animal heart that we've mapped, you can see that if you look at the middle images here to the right, as well as the right, during sympathetic stimulation, you significantly modulate action potential duration and local depolarization. And that really explains why sympathectomy works for patients who have had initial cardiac injury. As you can see here, this is what a sympathectomy actually is. It is the resection of the thoracic sympathetic chain, as shown here, by a surgeon, primarily done through video-assisted thoracoscopic surgery. And this surgery has been not only around for 100 years, first done by Tomas Ionesco, shown on the slide, they've actually been randomized clinical trials, such as this one by Peter Schwartz, where he actually showed the profound value of sympathectomy in patients with sudden cardiac death or at risk for sudden cardiac death. So this is really not a new concept at all. And with that said, I'd like to point out that there's a lot of data that suggests that cardiac sympathectomy is lifesaving as shown in this study here with 121 patients. And importantly, other forms of neuromodulation might actually be incredibly useful as shown here in this study from IU Penn, where they randomized patients with VT storm to sham or transcranial magnetic stimulation as shown here. And you can see that this form of neuromodulation dramatically reduced the ventricular arrhythmia episodes. So with that, I'd really just like to use these five minutes I have to be provocative and suggest that perhaps neuromodulation rather than the implantation of expensive devices might be a low cost solution to at least address a part of the population in Africa that's at risk of sudden death. And with that, I acknowledge my colleagues and thank you all so very much for your attention. Thank you. Good afternoon. So I was asked to speak on cost of EP services in Africa. As you can imagine, 54 countries analysis of EP and placing services, how are they paid in Africa? So speaking in five minutes, but I'm going to try to summarize. And I have no disclosure. So that will be my outline. I will introduce on the burden of cardiac arrhythmia in Africa, look at the availability of cardiac arrhythmia services in Africa, cost of EP and placing services in Africa, and I'll finish by conclusion. So cardiovascular disease, including cardiac arrhythmias are major public health problem in lower and middle income countries. And as you can imagine, there's a huge disparity in cardiovascular standard of care when compared to developed countries. So cardiac arrhythmias is really neglected area of cardiology as most of our previous speakers talk about. And there's lack of facilities and trained practitioner. And there's a discrepancy between high cost of diagnostic and treatment vis-a-vis budgets. Of course, political will by governments was also pointed out by previous speakers. The increase in the incidence of cardiovascular diseases and various factors are the significant effect on the burden of cardiovascular arrhythmias. Our health policy in Africa should really be aligned towards better management of cardiac arrhythmias. We have conducted several surveys that revealed a significant high cost of EP and placing services in Africa. Just last month, we have a survey on EP and placing services in 29 countries. That is more than 50% of African countries. And we have shown that nine countries does not have EP or cardiac placing services. So this is really alarming. And on report on service facilities that are providing cardiac arrhythmia services, most of the responders, about 75%, they have both public and private services. But some of the countries, they only have public hospitals and others around 10% of only private hospitals. In terms of payment, as previous speakers presented, most of our patients pay out of pocket. And you can imagine how high cost are these services and still many people are not insured. And very few centers do practice a public-private partnership, which is really helpful in countries where we have a huge gap in terms of payment. On availability of invasive services, we found that most of all countries that responded have temporary placing medical services. While on placing services and CRTs and other procedures like ablation, you can see the percentages are not really very promising. But good news is that when you compare with previous surveys, we've seen some improvement in terms of these activities. And our data really do some, when you compare with the 2018 PASCA survey and the 2020 PASCA survey, we don't see a lot of changes, very little improvement in terms of countries that have EP and cardiac placing services. On the cost of cardiac implantable electronic devices, we have seen that average cost of a single-chamber pacemaker is around 1,800 USD. On the dual-chamber pacemaker, average is around 3,000 USD. CRTD is around 10,000 USD. And CRTP is around 6,500 USD. And ICD is in the tune of 7,200 USD. And as you can imagine, these are really high cost when you compare per capita income of individuals in lower and middle-income countries. Similar findings is on average of cost for EP study is around 4,000, but a huge range of cost between countries ranging from 1,000 to 13,000. With ablation, simple ablation is around 4,000 and also high costs on the AFib ablation and VT ablation. In terms of industry that are offering these services, we have seen that Medtronic is leading in terms of the industry, but also Abbott follows and some other companies also there. And when we asked on what our responders talk about the cost, you can see that 86% of these patients really report that the costs are very high. And the reason for that is could be a high purchasing cost, lack of government support and insufficient implanters or electrophysiologists. For non-invasive diagnostic services, yes, some of them are usually available and probably relatively cheap, but other services like a 24-hour ECG, exercise treadmill, table testing are not available in some centers. ECHO is also available in tertiary hospitals and drug challenges for arrhythmias are also available in some centers. I won't talk of medical therapy because of time, but you can imagine also medical therapy for EP or cardiac arrhythmias is also a challenge. We don't have some medications in most of the countries and that is an area which needs to be discussed on. So in conclusion, the cost of EP and pacing procedures is high in relation to per capita income and there's a marked variation in cost across countries, as we have seen with single chamber and other procedures are really variant. And a possible solution could be to reuse cardiac implantable electronic devices, but as our colleagues said, some policy issues which really inhibit the use of implantable cardiac devices and also donation of medical equipment as a replacement, but advocates to access of technology and the issue of universal health coverage. I'd like to acknowledge my colleague, Professor Ashley Chin, who is in front of us there, who really was my mentor during my training, pacemaker at the University of Cape Town. Thank you so much. Good day and thank you to the organizing committee for the invitation. The topic I was given to speak on is pediatric electrophysiology in Africa, but data is limited and therefore I'll focus mainly on my local experience. So first of all, if we look at the South African population, we have a population of just over 60 and a half million people with the majority being based in Gauteng, the Western Cape and KwaZulu-Natal and vast distances between these centers. So with Healthcare in South Africa, we have got a private sector available in South Africa available only to patients with private health insurance, which is probably comparable to most first world countries. However, the majority of our population do not have private insurance and are serviced by the public sector where resources may be more limited. We have between 250 and 280 cardiologists in South Africa, but no one is entirely sure about the exact number as that not all cardiologists that are registered with the Health Professionals Council are still practicing or some have immigrated. And it's not a requirement to be a member of the South African Heart Association. So we're not entirely sure of the exact number of cardiologists. There are around 50 pediatric cardiologists, only 20 electrophysiologists with most of those being based in the big centers like we've discussed before, Gauteng, the Western Cape and KwaZulu-Natal. We have only two specialists in adult congenital heart disease and both of those are based in Cape Town, one private sector, one employed by the public sector. And there's only one pediatric electrophysiologist myself and I'm based in Cape Town. Of all these electrophysiologists, only two are employed by the government sector, both in Cape Town. We do have a number of electrophysiologists in private practice who also do outreach at the provincial or government hospitals in the area, mostly myself included, and that's mostly in Cape Town, Johannesburg and to a lesser degree in KwaZulu-Natal. So that leaves a vast majority of our population without access to electrophysiology services or even to general cardiology services. So I do realize that when we look at the rest of Africa, then in South Africa, we are still privileged compared to many other countries in Africa where cardiology services are even more limited. We know most of you might be aware of this data that was published by PASCAL in 2020 and they reported that only five countries in Africa were able to offer basic electrophysiology and ablation procedures, with only four being able to offer complex ablation using 3D mapping. No specific mention was made of pediatric or congenital electrophysiology. And in fact, at one of the first meetings of the African Heart Rhythm Association we had, I was invited and when I spoke of pediatric electrophysiology, some of the attendees were surprised that there was such a speciality and that any electrophysiology or ablation procedures were possible or offered to pediatric patients. So upon my return to South Africa after completing my fellowship, I've been based mainly in private practice in Cape Town, but I also do do cases at Red Cross Children's Hospital in Cape Town and Krasani Baragwanath Hospital in Johannesburg. On occasion I've had international colleagues come out and it's been great having that support where we would do a week of teaching and do more complex cases, mainly at Krasani Baragwanath Hospital. So at Red Cross we do have only a recording system and it's actually a very old recording system with limited capabilities. At Krasani Baragwanath recently managed to get a 3D mapping system so that has increased the scope of cases that we could do there. I currently do about 250 ablations per year of which 20% is in pediatric and adult congenital heart disease patients. I do get frequent telephonic WhatsApp or email consultations from all over South Africa and even from the rest of Sub-Saharan Africa, mostly from fellows who have completed their pediatric cardiology training in South Africa. So as you can imagine, that comes with its own unique challenges. It can be difficult to manage complex cases remotely. Patients have got vast distances to travel for follow-ups so they often go back to the referring cardiologist after their procedure. Might be healthcare providers who are not as familiar with congenital heart disease. There have been cases where they were not willing to cardiovert a patient with adult congenital heart disease. And there's also limited resources, especially when it comes to the rest of Africa outside South Africa. It's not uncommon to receive a consultation and then be told that they either have got no ECG machine, no defibrillator or no intravenous adenosine to manage a patient with. It might be limited availability of drugs to manage patients medically. And even if patients were to be candidates for ablation, it might be difficult for them financially or logistically to reach a center where they can be treated. There's also a lack of awareness, both among patients and healthcare providers that there is treatment available for both pediatric and adult congenital patients with arrhythmias. And this is why meetings like these are important. So we can raise awareness. It's also important, I think, that we get better data collection so that we can influence the decisions by policymakers. So thank you for your time. And please do feel free to contact me should you wish to discuss anything further. Hope to be with you at the next meeting. Good afternoon, everyone. It's a great pleasure to be here. I would like to thank Professor Mehrabad for really leading this AFRA group in a great direction. I think it's got new energy and I hope that you'll all become involved if you can. I have one disclosure that I'm not African. That may come as no surprise. But I have had the pleasure of helping with a few African cardiology projects and EP projects. And I'm sharing one of those with you now. So I'm talking briefly about building capacity in Rwanda. To build capacity in a country that is lacking it, which really applies to much of Africa, you need to start with political will. In Rwanda, at least, there is political will to expand the workforce. That means a sustained investment. It's not a matter of bringing somebody in for one day or one week or just one year. It really means that you're upgrading the health system, which has a long-term cost. You have to have a strategy for it. Again, visitors can come and boost ability, but all education needs to be part of a framework. And so you need the administrative structures to make that happen. And you need to be able to reassess them in an ongoing fashion. And personnel can be trained and expanded, but it requires the involvement of universities, the existing educational facilities in a country. Ideally, that's the most sustainable way to institute them. It may involve some training abroad, although we've seen the perils of a full training abroad sometimes means the doctor becomes a doctor abroad. So a combined in and out of country training may be desirable. Embracing the diaspora of a country is a way to keep interested people who were part of the country before involved in the ongoing improvement of the country. And interestingly, South-South collaborations, like the borrowing of Ethiopian experts to Rwanda recently can be very successful in expanding healthcare in a affordable manner. Infrastructure is so key and clinical facilities are just part of it. You also need learning spaces. You need laboratories. These are the things that our universities are composed of. Speaking briefly about Rwanda, it's a small country with a high population density. It took me a while to find a comparison, but it's like New Jersey's population density, a little bit higher than Massachusetts, for example. It's a small country, but lots of hills. The roads are mostly good. So that is a dynamic that affects access to care. Another thing of interest to a pediatric electrophysiologist is the median age. These are the ages, median ages of the continents of our world. And 18, that means half of the population in the continent of Africa is pediatric. Seems like a good place for me to go. And you can see that in developed countries in the West, like the US, you have a median age of 38, double the African median age. So the healthcare landscape in Rwanda has things in common with other African countries and some distinguishing features. In Rwanda, health insurance is compulsory, even though that insurance is usually not comprehensive. But 90% of the bill can be paid by the community-based health insurance. There is a well-organized structure of health centers, district hospitals, and then referral hospitals. Though I will caution that the path from one to the next can take a long time, sometimes longer than the evolution of the disease process you're dealing with. It's a forward-thinking health system with preventive services emphasized. The adoption of the HPV vaccine, for example, is better there than here. The big cardiac pathology that is new to an American working in Africa is rheumatic heart disease. It affects the valves, and it also affects the rhythm of patients starting before the age of 10 and really affecting their whole lives. Stereotypes of modern Rwanda are that it's a people that's reserved, but very welcoming to outsiders. They're early adopters. Medications and blood transfusions are transported by drone in Rwanda. They like new technology. They aspire to modernize. They're law-abiding. That's a distinguishing factor. It's a safe country. There's a sense of national unity everywhere that's tested, but I think there is a sense of national unity, and they partner well with foreigners. It's even 30 years later, important to note that there's still healing from a massive genocide in 94, which sort of set the country on its knees and really decimated the medical system. So everything there now is essentially new since 1994. So the task of a pediatric cardiology fellowship, and we're not talking EP yet, was offered by the Human Resources for Health, a health ministry secretariat, and funded by the ministry along with donations from a foundation. The faculty was two. There's one fully trained and one mostly trained pediatric cardiologist in the country for 14 million people. There's decaying infrastructure. The state hospital rooms are like the one you see here with eight patients per room, and basic needs met. Fellowships had never been done before, so pediatric cardiology started with a few other fellowships in a space where there had only been residencies prior. The process to put it together was bureaucratic. There were three standardized documents that had to be generated. It was hundreds of pages of curriculum material, largely based on Western and European and U.S. learning objectives, actually, at the request of the Rwandan docs. They didn't want a watered down, reduced, simplified curriculum. They wanted to train doctors very well. There was a review and ratification process also with four levels, or actually, I think there was a fifth level of ratification. And this ended up being a collaboration between the University of Michigan and the University of Rwanda to put this together. I was fortunate to have a Fulbright grant to start it all off. About three years into the development of the program, I could spend a year there. So here are the fellows, and here they were taking their three-year program. It was a blend of Rwandan and overseas training. So one of the fellows is currently in India and Bangalore obtaining high volume training in areas that aren't available in Rwanda. The fellows circulate between the three teaching hospitals in Kigali and benefit from the activity at teaching those places. When they're visiting teams coming, which has been the tradition for 20 years, fellows join those visiting teams in their activities. But that's actually a very small fraction of what goes on in Rwanda now. There were quality improvement in research activities included. It's always key to work with a local person who's invested in the program and that person is Emmanuel Rusengiza. Here he is wearing a Michigan sweatshirt. You can't escape the block M when you come to the United States. And he's right in front of my hospital in Ann Arbor, Michigan. He's a great guy and yet he was a reluctant champion. He was a Belgian trained and a very experienced pediatric cardiologist. But the ministry asked him to do this and he had a lot on his plate before that. So expanding capacity isn't always the interest of the practitioners in a country. It may be the desire overall, but they've got plenty on their plates. What was successful about doing this project was to have one-on-one time with fellows. That was something that the busy people there weren't able to give and I was in my role. Small group sessions, Michigan-Kigali joint conferences. There are people in this room who gave lectures who were Michigan faculty. There were learners from the US who came and these exchanges were very valuable. There were lots of challenges and they mostly stem from how hard it is to be a doctor in Africa. You've heard of some of this. The salary's low, the resources aren't always there. The healthcare workforce is stretched. The WhatsApp goes off constantly. It's really hard to deliver quality care. Something like tachycardia-induced cardiomyopathy is a lethal condition in Rwanda. So moving forward, they've enrolled another class of fellows and we remain involved. Parallel training efforts are underway in other cardiology areas, so that's great. And there's a growing surgical program thanks to hired expats. I'm trying to keep the partnership with the University of Michigan. These resources all around us are usually very eager to participate and the EP program is around the corner. There's a cardiac center being built and I'll show you a picture of what that's gonna look like. Here's the EP, a coming attraction and a weekly case conference that we began a year and a half ago that's still going. The new heart center being constructed in Kigali is gonna look something like this. It may not get finished on time, but when it does, I think it's gonna be really good. So I just have some points of advice to the clinical teacher from outside Africa. These are just some points that I learned and you can see a photo of the Rwandan and American fellows working together. Zoom is great, but it has its limits. The relationships that you rely on take a long time and take humility and there are times when you can't feel like you're making any progress, but you just have to show up again. It's key to support the local efforts and to empower the local academic clinicians and recognize their accomplishments in this difficult situation that they're in. And remembering that the US and European health models are the models that people turn to for excellence, but they also have their limitations. We would not recommend the American system to be an international standard. Embrace massive changes on short notice. That's something I had to get used to. Tomorrow, there will be a seven-day workshop beginning. That was the kind of thing that would sometimes come up and you have to get used to that. Bring your colleagues with you. So bringing even trainees was very helpful to model people who are used to learning from you. That was a very successful element in the year. And investment in costly technologies are part of cardiology, but they come slowly. Finally, Africa's full of smart learners, just like everywhere else. These learners wanna hear from you and wanna become great doctors. And it's just as satisfying to work with learners in Africa as it is in the US. Thanks so much. Good afternoon, everyone. Thank you so much for inviting me to speak at this meeting. I've been asked to speak on rheumatic heart disease. I do not have any disclosures. This will be my outline. I'm basically going to look at recent advances in this topic. We know that rheumatic heart disease have disappeared in high-income countries because of improvement in healthcare, as well as housing conditions. Most cases in these countries are in older age group who have this disease many years ago. Disease continues unabated in Africa and in Southeast Asia. A publication in 2007 drew the attention of the global community to this disease, which was almost forgotten. Recent registry such as Rheumatic Heart Remedy Study has brought to knowledge the current contemporary profile of this condition in Africa and in South Asia. The global burden of disease data shows that over 40 million people are affected. And the three main advances have increased our knowledge on the burden of rheumatic heart disease, big data sources, such as the GBD registry, RHD registries and countrywide administrative health data, as well as availability of screening echo. We today know that over 300,000 people die annually from RHD, representing about 1.6% of all mortality from cardiovascular disease. Africa, see has the highest prevalence of this condition and the highest age standardized disability adjusted life years lost to RHD. It's observed in the Oceania, as well as in the South Asia. In areas like Australia and New Zealand, higher rates have been reported in indigenous population. Although most data report female predominance, we know that there's no gender difference in the complications. Advances in the understanding of rheumatic heart disease, although we know traditionally about the molecular mimicry theory, a new theory has been proposed, which involves collagen binding factors, which leads to aggregation of collagen and autoimmune response and incitement of inflammation in tissues, which leads to rheumatic heart fever and subsequently rheumatic heart disease. Other superficial chronic infections have also been associated with rheumatic heart fever, such as emphytaigo and pyogenic pyoderma. We also know today that group A is implicated, group C and G, streptococcus, are also contributing to the pathogenesis of rheumatic heart disease. A lot of genetic polymorphisms related to this disease have been defined. Interleukins have been found to be associated with clinical disease. Interleukin-4 differentiates latent from clinical rheumatic heart disease. Interleukin-4 and it predicts progression from latent to clinical disease. A high levels of interleukin-10 and interleukin-4 level predict advanced clinical outcome. Advances, so that use of GWACs have shown that rheumatic heart disease has a significant heritability, which is likely polygenic. In terms of clinical features, rheumatic heart disease profile has been documented by some registry like the Pre-Med Registry. All we know today is that there's late presentation of this disease, established complications in endemic areas, there's recurrent hospitalization, there's early mortality, and mean age of death is about 29 years. And most deaths occur within the first three months of diagnosis. In terms of advances in primordial prevention, we now know that housing condition contributes a lot to the risk of GIS infection. The housing, indwelling characteristics, construction, type of housing condition, dampness and vaccination, and it can be targets of prevention. There are also efforts in developing vaccines against septic infection. And this is happening in Australia, in Brazil, in Canada and the United States. But most vaccines are still in the pre-clinical testing stage. We know also there are advances in primary prevention. Clinical decision rules have been developed in many countries. Rapid antigen tests have also developed, but this is expensive for developing countries. Nucleic acid amplification test is also available, but it's better than the rapid antigen detection test. Electrochemical detection, which uses DNA, has been proposed. Machine learning and AI techniques have also been proposed for the diagnosis of strep infection. We now know today that penicillin still remains a first-line drug for prophylaxis, and two Cochrane studies have shown that this is so. However, there have been developments to improve the use of penicillin, for example, additional glucaine and pain distraction methods, as well as implantation and longer-acting penicillin G delivery devices. Community, as well as provider knowledge and awareness, remains a pillar in primary prevention, and this can be improved through the internet and electronic devices. For secondary prevention, revision of Jones criteria has been made to be useful in low-risk resource settings. There are also ongoing attempts to identify unique immune signature that could be used to diagnose acute rheumatic fever. As we know, ARF is currently a clinical diagnosis. In many countries, they are also trying to establish esoteric that is useful for their environment, and recent evidence also shows the benefit of antibiotic prophylaxis in latent rheumatic heart disease. Potentiary prevention, valve surgery versus valve replacement. Mitral valve repair is better. Balloon mitral valvoplasty is better than valvotomy. There are also attempts to use TAVI to treat aortic stenosis from rheumatic heart disease. There has not been any improvement in medical therapy for this condition. In terms of atrial fibrillation, rheumatic heart disease, VKS still remains the drug of choice. Infective endocarditis prophylaxis is recommended for high-risk patients, but this is controversial, especially in poor resource settings where the hygiene level is low. However, good dental hygiene and regular dental cleaning is recommended in this patient. For pregnant women with rheumatic heart disease, this has been diagnosed in many developing countries. However, the remedy study shows that a lot of women are picked up in pregnancy, and there is no established program for these women for pre-conception counseling or family planning or family planning for them. Only about 5% of women with prosthetic valve and 2% of women with severe mitral stenosis in the remedy study were on contraception. Other recent advances, there has been an increase in global awareness and global efforts, advocacy and stakeholder engagement in the fight against rheumatic heart disease. We have also better understanding on RAG-associated costs in endemic areas. Both primary prevention and secondary prevention are cost-saving and cost-effective. As in terms of co-infection with HIV, especially endemic places like Africa, a study from Uganda shows that there's no difference in outcome. However, patients who have rheumatic heart disease tend to have higher rates of stroke. So in conclusion, rapid progress towards global elimination of rheumatic heart disease as occurred in recent years and use of new scientific techniques for improving prevention, diagnosis and treatment have the potential to ensure this revolution. Progress is being made in area of basic sciences and clinical science and translation as well as population science. This progress requires investment in research funding and resources for educational awareness as well as capacity building. It is possible to eliminate rheumatic heart disease in our lifetime. Thank you very much for inviting me. So we relatively privileged in South Africa in a sense that we have an ongoing clinical EP both adult and pediatric. So one of the things that I've decided to do over the last 13 years that I've been in private practice for is creation of data because one of the things that irks me more is that when all Africans of all races but in Africa, the first thing that you do is that in U.S. this is what they do, in Europe this is what they do. So we're creating our own data. So we have two registries that are running concurrently, one run by Ashley, one run by me. So I'm just gonna give you my experience. So we started connection system pacing at the inception and like everyone else, we're doing his spinal pacing which we are funding for obvious reasons. And then we started moving into left spinal area pacing and we have currently close to 350 patients in the registry. So I'm gonna share with you our experience because of course we adopted very early on the, instead of using the lumen-less lead from Medtronic which was quite expensive, we went to with a study-driven lead because it's quite cheap. And also the fact that a lot of cardiologists were used to this lead. So even if it dislodged, you can just put in the RV Apex. So there was nothing new to them. So we adopted that very early on. So there are kind of videos that maybe in interest of time, I'm not gonna play, but basically we do some of the things. So we like to do ventriculograms just to make sure that we limit the likelihood of septal lead entrapments. We also give ourselves a geography where we're gonna start mapping for where we wanna be at. So we do do these ventriculograms. They are not necessary, but for teaching purposes, they are quite important. As you can see, the distal end is where you don't want to be and proximal end you also don't want to be at because of the lead entrapment. We also do septograms just to make sure that we align our guide and catheters in the way that we want to expedite the delivery of the lead. Nothing new there, but we do that all the time. Obviously, if there's some renal impairment, we don't do that. And I'm gonna quickly go through the slides for those who are interested in talking to me afterwards, they can come, but I'm not gonna spend a lot of time on this. So we either deliver the lead while pacing or deliver the lead without pacing. In this case, we'll see what we call fixation patterns, which basically tells you how far you are and when you should stop. So you can see from V1 in the native lead and changing and morphology becoming the right by the branch morphology without any fluoroscopy or anything else, you know that you need to stop at that point because you're probably at the right place. We also use a lot of current of injury rather than impedance based because we know that if the lead is still well within the myocardium, the current of injury would probably gonna be 20 and above. If you have anything below four, you probably have imminent LV perforation. So we use that more than we use the impedance. And also remember the impedance differs from one lab to another, depending on the cable connection and other issues. So this is a patient of mine you can see here, we have a current of injury that is well under five, not only that, but it starts with a Q and we kind of knew that something was gonna happen. And I'm gonna play you this video, hopefully you can see. So you saw the current of injury was low. It doesn't look good, right? But you know, we do echocardiograms and then none of these patients end up with ventricular septal defects that are clinical, but you can see that's a huge perforation, right? So we use the current of injury to gauge ourselves where we are at. We also just make sure, so when we started like everyone else, so we had learning curve, which apparently you need 100 cases for left bundle error pacing, I didn't know that. So we were not sure at the beginning whether we're doing left bundle pacing or we're doing septal pacing, but in the last 100 patients or so, we just make sure that we go through all the stages of confirmation that we are capturing the left bundle rather than a deep septal or left ventricular septal. So you can see here, soon after implantation, there's still a differential in terms of capture electrophysiology of the local myocardium versus the left bundle, whereby most of the time, because of the injury to the muscle, the capture thresholds are different. So you can see moving from what you call non-selective to selective. So we go through that. How do you know on this slide? We know that if you look in V1, there's a change where you look at those two arrows in terms of the R prime, but without the change in left ventricular activation, which is 72, I'm not sure you can see and appreciate those two rings. So that's a change from non-selective to selective. And it also tells you or confirms to you that you're in the right place. If you think you're in the right place, but you're just not getting the right bundle branch morphology, the other thing you can do is just a basic EP where you pace and give S2 or S3, as Marek has described in his papers, where you can see in V1, which is coded as red, from left to right, as I'm pacing, there's no right bundle branch morphology, but when you give S3, then you get right bundle branch morphology. It's also a way to let you know that you're probably in the right place. And we use all these criteria to decide whether, once again, you're in that right place. I mean, those who are interested will know what these figures mean, but basically you want to capture the LV very early on. We don't really like, well, we like looking for it, but we don't spend a lot of time looking for bundle potentials. Where we feel right from the beginning that we may be dealing with a patient with a distal disease, probably distal to where we want to be at, looking at this patient's got a HV of 90, got left axis deviation. Then we kind of like plan that we may have to do coronary sinus epicardial lead as per conventional, so that would be hot or not. And you can see the changes in ECG are quite good. A bit of a technique sometimes, if you're going to have to have a left bundle error pacing lead, but you want to optimize a QRS and put in the LV lead, you can actually tie the two before you accept that you've got in the LV, that is good. So if you look at these changes when I'm connecting and disconnecting the two leads, changes in morphology. So I already know how it's going to look like. I'm not sure if you can appreciate in the red that this morphology keeps changing, because sometimes you only know once you have all the leads where you think they are good, but the QRS morphology is not good. So there's a trick that you can learn. So you can take what you're deploying to what has been deployed. And then in an art, you just run these two leads at the same time. It's a trick that's nice. We don't usually try to do right bundle pacing, but this was serendipity where you kind of find the lead in the right bundle area. So we do do right bundle pacing. It's not something that we do all the time, but this is a case that we did by bundle pacing very early on. I think we were the first people to report by bundle pacing in patient with cardiomyopathies. And you can see the differences in the ECG there. So what we have is over the last four or five years, we have learned quite a bit. We have a relatively good success rate. We've used the current criteria where we want to be at. We have almost 300 patients that we have studied. Remember we said the whole registry has about 30 and 50 patients, but those with follow-ups of at least more than three months is what we have. So 50% are men. Most of the indications are heart failure and most of them are 66. I mean the median age is 66. So what we have learned from that is something that we already know that the pacing impedance and the lead stability, it's better with left bundle area pacing compared to the years. There was nothing new there. The reduction in QRS ejection friction change was the same. What surprised me though was personally, I find his bundle pacing a bit more challenging compared to left bundle area pacing, but the fluoroscopy time was the same though, no difference. So that was something that was a bit of a surprise for me. Then we looked at the patients that are kind of like before you even implant, you think, okay, I made failure. So we look at the patient with a very wide QRS of 160 and above milliseconds, and we realized that the wider the QRS, I guess it makes sense, but you don't know if it's going to be like that, but the wider the QRS, the more likely you're going to reduce the QRS. So you can see those who are between 120 and 159, the reduction in the mean was about 26, but with the QRS of 160 and above, it was 50, minus 50, which was clinically significant. However, the ejection change to my surprise, there's no difference between the very wide and kind of like acceptable or what we see often, which is like 120 and 159. The fluoroscopy time, I guess it was expected to be much longer for those patients with a wide QRS because they tend to have a more severe disease. So in conclusion, the hispanic pacing and the left panoramic range error pacing in our hands reduces the QRS the same way. The ejection improvement is similar, but with lower implant pacing threshold as well as follow-up. So that was something that probably we didn't think it was going to be any different. But for those with very wide QRS compared to between 120 and 159, the QRS reduction was more pronounced in the wider group and the fluoroscopy time was wider in the fluoroscopic group. The left ventricular ejection change was similar in these two groups, which came a bit as a surprise because I didn't think it was going to be like that. So in conclusion, we have a data that is going on and we'd like to collaborate with other people from other different continents and within our own continent where we can drive these registries that we have in South Africa. And it's quite, in my experience, I think connection system pacing is much easier than the conventional biventricular pacing. And I think it's going to be the way for the future. What we didn't factor into this registry is cost effectiveness, but we're starting to see the numbers that it's going to be much more cost effective than biventricular pacing. Thank you very much. So as we've seen today, the CIED implantations in Africa are growing and they're expected to grow exponentially as we make this change from primarily infectious disease to non-communicable diseases. And this has been shown repeatedly today. But unfortunately, infections are also common. And with the increasing number of implants, we are going to see more and more infections in the African continent. Sometimes it'll be very obvious, like in the bottom examples of frank perforations of devices, sometimes it's more subtle. And occasionally also in folks of darker skin color, it may even be delayed in recognition. And so this is a reason to think about this in Africa. Now, in the top left panel, you see that the infection and the complication rate is really related to what type of device you're implanting. Pacemakers take less time in smaller ICDs have an increased infection rate. And of course, CRTs, the more complicated devices, have infection rates that are approached 2%. And these are numbers from North America. And of course, the longer the patients have their devices, the infectious rate is cumulative. And so in this study, infections occurred in the mean of about 3.7 years with a 1.1% incidence. Again, this is North American data. And the risk of relapse of infection without complete and total removal is very high. Infection and relapse occurs in close to 100% of cases when you have partial removal of the device or treat with antibiotic alone as compared to 0% to 4.2% if the entire system can be removed. So early and complete removal of infected systems saves lives. And I'll bring your attention specifically to this number right here. If you compare antibiotics only versus complete removal of the device, you will be seeing a sevenfold mortality difference. And in terms of taking out the devices very rapidly, immediate device, which is removal within the week of recognition of an infection versus delayed, provides more or less a threefold survival benefit. So time is of the essence. Because of all this, device-related infections are indicated to be removed. And this is sort of unanimous across all the major heart rhythm societies across the country, both to remove them entirely and promptly. The problem for Africa is that lead extraction can be a very resource-intensive undertaking. Yes, we generally begin with just lead-locking stylettes, which are relatively inexpensive. But beyond that, we're talking about quite sophisticated and specialized equipment. So here we have examples of mechanical extractors, laser-assisted lead systems, the bridge balloon that can be replaced in the superior vena cava to give us time in the case of SVC tear, and of course, the panoply of stylettes that we use to sometimes go in and reach and pull out leads. Also, in most centers in the United States, we use high-definition, three-dimensional CAT scanning prior to an elective extraction. And that can be very useful to identify situations like you see in the bottom left of extravascular leads before you get in. And it can also help you decide whether you're going to take this case on or should it be better addressed in an open fashion. That being said, the complication rate for lead extraction is not as high as is generally believed. And in fact, in this paper by my colleague, Emily Zeitler at Dartmouth, in comparing major adverse events and mortality across things that we do on a routine basis, you see that the mortality of the lead extraction compares with that of an afib ablation. And in fact, if you look at major adverse events, it is lower than an afib ablation. And so, than an afib ablation or a percutaneous intervention. Now, this is where the African angle is very important to take. The concentration of experience is true for so many of our procedural procedures. It really helps improve the outcome. So, if you take a look at the left panel here, data from North America between 2003 and 2015 reports about a 10% complication rate for lead extraction and a 4% overall mortality. If you look on the left, on the other hand, this is a single center data. Actually, in this case, a European center. And you see that the center has explanted close to 2,000 leads at the time of the reporting and have been able to bring their mortality rate down to below 0.1% with a 97% success in complete extraction of devices. And so, this is sort of two examples to really demonstrate the importance of concentrating the experience. And I think the same thing is going to be necessary when we face this impending tsunami of lead infections that we may see in Africa. So, how do we train our physicians? There's a 2009 consensus statement that speaks to this. Operators should do at least 40 leads extractions on their own completely independently, but supervised by a well-trained extractor. That well-trained extractor themselves should have extracted about 75 leads. And then to maintain competency, it's recommended that you remove 20 leads a year. I think these are very small numbers. And in reality, the top centers in the world do considerably more than that. Just a word about the African experience. This is from Professor Mkoko in Cape Town. They described their lead extraction data. If you'll focus to the middle column here, only 26 patients were extracted as opposed to simple explantation. So, using mechanical extraction sheets for the most part, and had a 3.8% in-hospital mortality, just a single patient. Another South-South collaboration, this is not from Africa, but in Chile, reporting in HeartRhythm02, their very early experience with lead extraction, just 15 patients, but again, able to do so with zero mortality and a 1% complication rate. And so, in conclusion, ladies and gentlemen, I'd say that Africa is poised to face increasing numbers of patients requiring lead extractions. This is just as we increase implantations, but also as these new implants come for generator changes. We're going to see a lot of infections at that point. And of course, as leads age. I think that AFRA and other stakeholders, as we've heard today, should proactively identify and support key regional centers of excellence where we can train and refer difficult cases for this high-complexity procedure. And the results should be transparent and best practices should be shared as we've been showed you a few examples today. Thank you. Thank you for the opportunity to present. My remit will be to discuss how the cardiac can be used for the diagnosis of myocardial infarction in Africa. Here are my conflicts of interest. So the problem really is how myocardial infarction is diagnosed. And as you can see from this study, not many countries in Africa have data on the prevalence of myocardial infarction. And this probably is due to the fact that ECG equipment is not available. So the problem with myocardial infarction is getting towards the clinical diagnosis and then more importantly, getting that ECG to make the diagnosis. Treatment is not within the remit of this presentation, but I want to touch upon the availability interpretation and the costs of the 12 lead ECG. And so recently the cardiac 6L has shown the ability to record six lead ECGs and this is available for clinical use. This has expanded the indication of this device. And what are therefore the advantages of this over a 12 lead ECG? Firstly, the device is very portable. It is much cheaper. It requires fewer consumables, for example, ECG electrodes, and ECGs can be transferred from one center to another seamlessly. So the question therefore is, can the cardiac be used for the diagnosis of myocardial infarction? And we know now that handheld ECGs have a potentially useful role where 12 lead ECGs are not available. And this has been clearly demonstrated where it comes to rhythm diagnosis, for example, of atrial fibrillation. In 2021, we published one of the first studies validating the cardiac 6L versus the 12 lead ECG. In this study, we showed that the limb lead equivalents of the cardiac 6L fared very well compared to the 12 lead limb lead ECGs. And therefore, the question was at that point, can the cardiac 6L do more? And this started off as an idea which was published in 2020, where the cardiac 6L was attached in the chest configuration to acquire chest lead ECGs. This required extra accessories, but the device has been modified and the software updated so that chest lead equivalents can be obtained without the use of any extra accessories as shown on this figure. So the device is simply placed on the chest and the respective chest lead is recorded. With improved software and algorithms, therefore, and potentially the use of AI gathering some ECGs from the chest can allow the simulation of a full 12 lead ECG. And this has important implications because if a 12 lead ECG can be recorded, then in the case of myocardial infarction, the diagnosis can be made quickly. And importantly, treatment can be started early. So the patient does not have to be transferred to a center where an ECG is available. The diagnosis can be made on the spot. In the ACC in 2022, data was presented showing that the chest leads validated very well when compared to the equivalent chest leads on the 12 lead ECG. And in particular, it was thought that V2 and V4 provide specific discriminators for myocardial infarction. And here from the local ECG, you can see an example of a 12 lead and a 6 lead ECG. And indeed, the electrocardiograms are very comparable. Therefore, what is the role for the cardiac for the diagnosis of MI in Africa? I think there is a potential important role as software and data acquisition is improved. The device is portable and cheap. AI can simulate the 12 lead ECG, and there are certain implications for diagnosis and treatment. Thank you very much. All right. Good afternoon, everyone. So my task today, I was asked to give a talk on the EP impact of forgotten heart diseases in Africa. I quite enjoyed sort of preparing for this because I learned a lot in the preparation. And like David, I am a genuine African, and I'm third generation South African and proud of that. So Anna Mokumbi from Mozambique, for those who might know, sort of published this provocative article in Jack in 2010, where she was asked to give a review on the neglected cardiovascular diseases of Africa, challenges and opportunities. And she defined neglected as being those diseases that predominantly affect Africans, but it's not been subjected to intensive systematic research where the epidemiology of the diseases and the natural history is quite poorly understood. And she came up with a list of diseases that I think probably many of you might, if you work in Africa, have been exposed to, but probably from the developed world have less experience with. Rheumatic heart disease, endomyocardial fibrosis, peripartum cardiomyopathy, TB, systolesomiasis, tachy-issues, and subvalve aneurysms. And so I thought for this talk, I'd concentrate on four of those diseases. And my task was to really speak about the impact of these diseases. So I'm going to be concentrating on sort of some of the studies that show some of the incidents and the prevalences of these diseases. And then just to highlight the clinical arrhythmic presentations, and then discuss some brief African studies which have contributed to the literature. Next talk is actually going to be on rheumatic heart disease, but I'm going to show you four slides because I think it's important just to highlight the problem of rheumatic heart disease in the developing world. Here's a slide on the prevalence of rheumatic heart disease. And this was a study that looked at both clinical and echocardiographic imaging from two countries, from Mozambique and from Cambodia. And what you can see is that sub-Saharan Africa is still the hotspot of the world for rheumatic heart disease, affecting about 30 out of a thousand school children. Okay. And this is echostudy. And I think still in my practice, I have to do general cardiology as well. There's not a week that goes by before I have to see and manage a patient with chronic rheumatic heart disease. So this is a disease that's very much still prevalent. This is a big study that was run by one of our colleagues at the University of Cape Town, Professor Zulka, called the Remedy Registry, where she looked at over 3,000 rheumatic heart disease patients, mainly from, it was an international study. A lot of the patients were enrolled from Africa. And she basically looked at the baseline characteristics and the two-year outcomes for patients with rheumatic heart disease. And what is striking is that about 18% of the patients had underlying atrial fibrillation at baseline. But what's more concerning at two-year outcomes, the outcomes of death, stroke, systemic embolism, or major bleeding was as high as about 20, was almost 20% over two years. So the rheumatic heart disease-related mortality, heart failure, and stroke remain unacceptably high. This was a study that I was involved with from the, with PHRI in Hamilton, Ontario, and it was called the Relia of Registry. And this looked at really patients who presented with a diagnosis of atrial fibrillation to the emergency room across multiple continents. But if I focus here on those patients who had underlying rheumatic heart disease, it accounted for about 12% of patients. But when you looked at particularly the African sub-cohort, in Africa, rheumatic heart disease accounted for about 21%. So almost double what the rest of the world was seeing for patients presented with atrial fibrillation. And with a high annual stroke risk ranging from about 1.6 to about 6.4%. The INVICTUS trial, which was also run out of PHRI in Canada, but was really, the main author was the late Professor Bogani Moyose at the University of Cape Town. And I just wanted to show you here the results of the INVICTUS trial, which was a randomized trial comparing rivaroxaban with vitamin K antagonists. And surprisingly, in fact, vitamin K antagonists did better than underlying rivaroxaban. But I think what was more important were another important aspect from this paper was that it highlighted the high mortality rates in patients with underlying rheumatic heart disease, and especially once atrial fibrillation develops. These are usually patients who are sort of at the severe disease, and patients that need to be referred for valve replacement. And I think a large percentage of why the mortality was so high is that in some countries, this was not available. And I think the comment by Professor Gregory Lippert that in his editorial to the New England was, to improve outcomes in rheumatic heart disease patients, we therefore need to look beyond vitamin K antagonists alone, highlighting the importance of heart failure and referral for appropriate valve surgery. What I don't see a lot about, what I don't see a lot unlike rheumatic heart disease in South Africa is endomyocardial fibrosis. And this is a disease of the tropics in Africa. This was one of the studies that I found, again, from Professor Bakumbi that looked at the prevalence of underlying endomyocardial fibrosis in Mozambique. And what you can see is that it was really, really starking for me. The estimated prevalence by echocardiographic screening was in the region of about 20%. What you can see here is that the highest rates, highest prevalence rates were in young people between the ages of about 10 and 30 years of age, with prevalence rates as high as 30% in those age groups. Endemic cardioprebrosis has been called the most neglected cardiovascular disease that we know, right, and there's very, very poor research into this particular area. The etiology is still debated. For those who have seen patients, it's usually manifested as a really an advanced restrictive cardiomyopathy, mostly right heart failure. But remember that arrhythmias can be a manifestation of endemic cardioprebrosis. Atrial fibrillation being the most common, first degree conduction system abnormalities like first degree heart block and rheumatic and right bundle branch block has been reported. And I've been involved with a single case with, in fact, Brian referred us a case with intractable VT presenting as initially we thought ARVC, but in fact had endomyocardial fibrosis. So this is a disease that I think is really understudied and it needs to be a focus for future studies. What about TB? Okay, TB, we often think about how does TB affect the heart? Well, it usually involves the pericardium and patients present with massive pericardial infusion, sometimes constriction. But what we often forget is that arrhythmias are sometimes the manifestations of underlying cardiac TB. Here in South Africa, we have one of the highest incidence rates of TB worldwide. In fact, the Western Cape where I practice, it's one of the highest in the world where the incidence rate is about 500 per 100,000 per year. TB myocarditis, however, has still been thought to be a rare finding, which in some studies have been reported about 0.1 to about 2%. And I'm going to be a bit provocative here and say that probably we're missing this diagnosis. Here's one of another African study. It was looking at the systematic review on how patients present with TB myocarditis. You can see that they only had a handful of patients in the systematic review. And I think it's definitely underreported. Probably most patients are asymptomatic. But what highlighted the study highlighted is that it's an important cause of sudden cardiac death. And treating these patients with palmary TB, I was always shocked when I was in my fellowship in being a registrar, while patients would suddenly die overnight. We would often say it's probably the massive hemoptysis that people were getting, or the patients died from apoxic palmary disease. But in fact, maybe some of these patients died from underlying cardiac arrhythmias. It's well known that TB is associated with heart failure, can cause ventricular tachycardia, and also obstruction because of the underlying masses that can grow in the heart with palmary TB. Now where it gets a bit murky is does PTB cause heart block? And this was something that I was interested in when there were a few studies coming out from India about whether TB is an important cause of heart block. So we looked at our data from the INPE study. The INPE study was a large study of patients who presented with underlying pericardial TB and attested the hypothesis of where the prednisone reduced the incidence of constriction in these patients. But we were more interested in looking at what was the underlying rhythm abnormalities in these patients. And what we found was that interestingly, in baseline ECGs of over, I think it was over 1000 patients, we didn't find any second degree. This is isolated ECGs, and that's a major limitation, but we didn't find any patients with underlying second or third degree heart block. There were a few patients who had first degree AV block. But so it suggests maybe that in patients with underlying pericardial involvement that heart block is unlikely. But again, these patients were in predominantly TB myocarditis. We also looked at our patients who presented with young heart blocks to our institution. And a large percentage of patients were idiopathic. We didn't look at particular patients who presented with underlying TB and heart block, and we might be missing these patients. Lastly, what about this rare condition? I think it's quite a rare condition called the subvalvomitral aneurysm. I think it was initially described in young Africans in the 1960s, and the proposed etiology is very, very unclear at the moment still. Postulated mechanisms include congenital, and some patients have there been biopsy studies of aneurysms at the time of cardiac surgical repair, showing underlying Ashoff bodies consistent with rheumatic heart disease, and also TB findings. And possibly this is the underlying mechanism or one of the mechanisms that's contributing to these submitral valvular aneurysms. I've seen some patients who had ruptures of these aneurysms, sometimes it's coronary artery compression. But importantly, that these patients can also present with ventricular arrhythmias. And I've had an experience with that, as well as sudden cardiac death. This is a series of patients that was published early in the 2000s from our institution, looking at about only about 12 patients with subvalvular aneurysms. And in fact, four of these patients, so about a quarter of the patients had underlying TB or rheumatic heart disease. So probably a disease that's more seen in the developing world. So in summary, then I've shown you some neglected diseases that are still highly prevalent in Africa. Arrhythmias are sometimes forgotten as manifestations or complications of these common diseases. I think what's important is that more prevalence and screening studies are needed to estimate the disease burden. More funding for research should be prioritized. And rheumatic heart disease, I think, has really served as a blueprint for other neglected diseases. I think there's a need for increasing healthcare spending needed for especially cardiac imaging. A lot of these diseases require cardiac MRIs and underlying PET scans, which are often not available in developing countries. And then medications needed to treat them, like anticoagulants, as well as surgery and ablations and pacemakers we've spoken about. And that the teaching and training of cardiac specialists are urgently needed to manage these complex diseases. Thanks very much. Good afternoon, Chairs. My name is Amam Mbakwe from College of Medicine, University of Vegas. I'd like to appreciate AFRA and HRS for asking me to speak at this summit. I've been asked to talk briefly on atrial fibrillation management in Africa. I have nothing to declare as regards this presentation. I'd like to discuss this topic and using this outline in the next few minutes. We've got introduction, management principles in atrial fibrillation. We look at what are the peculiarities in Africa, what are the roadblocks, and the way forward. We all know that atrial fibrillation is the most clinically important arrhythmia requiring hospital care. And global incidence is projected to increase in the next decade as the population ages, and also with a plethora of risk factors. Prevalence in Africa has been put at less than 1%. The global burden of disease in 2017 actually put the prevalence at 0.13%. There's been a lot of arguments about whether this is a true prevalence or that we're not detecting the atrial fibrillation because the risk factors driving AF is predominant in Africa, and we know that control is quite poor. So that does not tally with the role of, with the low prevalence, but that stands to be debated. Looking at more of the epidemiology, about 3.6 million people worldwide in 2016 are said to be living with atrial fibrillation, you know, with substantial morbidity and mortality, 2% to 4% prevalence, you know, worldwide, and the risk is expected to rise, as was said earlier on. And the rise is more, you know, for those, for the elderly people. And we say that, and it's said that a lifetime risk for AF, especially for Europeans, would be 1 in 3 adults. The European Society of Cardiology had classified, you know, the management, stratified the management of atrial fibrillation, you know, the acronym CC2ABC, you know, confirming the atrial fibrillation and characterizing, you know, the atrial fibrillation, and then the ABC talking about anticoagulation, you know, better symptom control and management of comorbidities. But what are the challenges we face in Africa? You know, diagnosis is hampered by so many reasons, you know, poor availability of ECG machines, because we can't really, you know, confirm atrial fibrillation, except you can get an ECG done. And even when the ECG is done, there may not be enough, you know, skills for interpretation and characterization of the disease using the four S as stated in the ESC guidelines. The next, you know, problem or challenge is anticoagulation for stroke prevention. There's poor availability and use of drugs, majorly what is used in the VKAs. And then with the VKAs, you have few anticoagulation clinics, long distances for patients to access frequent reviews, and also the cost of PTI and R, which is usually paid for by patients out of pocket payment, you know, hampers, you know, good control with VKAs, and also short duration of being in therapeutic range that has been shown, you know, by so many studies that a lot of Africans and not the therapeutic range are suspected. In fact, one of the studies show that TTR range in Africa was 13.7%, and, you know, to 57.3%, which is below, you know, the stipulated best practice of more than 65%. The other management problems, there's poor access and availability to electrophysiological services, poor availability of medications for rhythm control, management majorly with rate control medications, and then poor access to care, generally. So what are their met needs? So we can look at them at different levels, the care setting and policy, you know, levels, you know, we need to diagnose early, you know, the early and accurate diagnosis of non-valvular atrial fibrillation, so proper history examination of the PAWS and ECG index, like we said earlier, and correct stroke risk assessment. There's also poor drug regimen, you know, accurate and evidence-based risk profiling, using the, you know, risk cause for stroke and for bleeding, and proper patient profiling for agent selection. And major factor is either over or under anticoagulation in our setting. At the patient level, patients identified most important areas for more education and information, because we need to get the patients on board if we're going to get good control. Education on modifiable causes, AF-related complications, and lowering stroke risk is most important to the patient. And this is taken from the roadmap of the World Heart Federation on atrial fibrillation, looking at the important, you know, the things the patient considered important for them, where they needed more information, more education. What are the policy level? You know, policymakers should try and reduce the high cost of care, and out-of-patient pocket expenditure is not helping, you know, the management of this disease. Access to care, lack of trained personnel, long-distance, you know, travel to access healthcare is also hampering the proper management of atrial fibrillation in our setting. And also at the policy level, if the policymakers can implement universal healthcare, you know, that will cover a lot more patients and will then avail them the proper care for atrial fibrillation. Thank you so much for your attention, and I'll be ready to take questions. Ethiopia is a huge country, the second most populous country in Africa, with 120 million inhabitants and only 50 cardiologists. I wanted to take part in this effort to improve the health of this country, which is particularly important to me. I met the Ethiopian ambassador in Paris, who introduced me to a cardiology team in Addis Ababa. My first mission was held in May 2021, and I met this team during the COVID-19 pandemic, these cardiologists, heart surgeons, this very close-knit team, very competent, but obviously lacking everything. And we were able to implant 20 pacemakers and probes, of course, that I had brought, which were offered by the biomedical industry, that I had brought in my suitcases. I was surprised, by the way, that most of the patients had complete B.A.V. at QRS-FIN, of course, all the others more unstable at QRS-LARGE. Unfortunately, they could not wait to be implanted. We shared a very fruitful experience, we built a very strong friendship, we gave courses to students who were very eager to learn rhythmology data that they did not know well. And then, of course, very touched by the sharing of these families, so recognisable through all these generations, as we can see in the eyes of this family. My second mission was held in March 2022, and this time at the Cardiac Centre Ethiopia, unfortunately, there was a failure of the laboratory, the radio did not work, and we had to work at St. Peter's. Here again, the equipment that I bring in my suitcases, pacemakers, are small equipment, and on this occasion, for the first time, we were able to work jointly with the two centres and bring our efforts together, share our knowledge and implant common patients. I would like to greet the paramedical staff, very involved, very dedicated, and at the end of the mission, when we had implanted 20 patients again, I noticed that under the table there was an amplifier and a complete electrophysiology system, an ortho-rhythmic stimulator that had never been used before, due to lack of competence. Seeing this, I said to myself, let's try to build for the next mission, a feasibility mission for electrophysiology. This third mission was held in December 2022, and we were able to bring, this time again, I was able to bring a frequency radio generator, which was offered by the industry, catheters, ablation centres. And we obviously implanted patients, pacemakers, but above all, this was the first ablation carried out in Ethiopia, a mid-septal celt, which went wonderfully well, and which made it possible to demonstrate the feasibility, but also the safety of electrophysiology in this country and in this Catalan. Which led me to carry out this fourth mission in December 2023, last Christmas, and this time the electrophysiology laboratory was there, waiting for us, and of course, we also implanted 16 patients, and I was able to carry out this ablation by catheter in a very successful way. And as you can see on this slide, I was even able to do, in a conventional way, two left lateral access roads, by transseptal route, with a perfect result, and in good safety conditions. So what comes next? Obviously, I tried to communicate through institutional societies, like HRS and others today, and social media, which allowed me to announce to my friends, my electrophysiologist colleagues, come and work at Addis Abeba, there is an electrophysiology laboratory, if you want to work, it's possible. And then I was able to meet, thanks to this, other American associations, in particular, who wish to merge our efforts and try to improve electrophysiology in the country. Obviously, you have to bring equipment, catheters, pacemakers, why not a 3D system one day? And what is very important is to identify a person, a young cardiologist, to whom we would give an electrophysiology education. Eventually, we could get him to come, to give him a better knowledge of the specialty. And why not propose, subsequently, remote electrophysiology sessions, which would eventually be supervised by cameras and webcams. This is also a completely possible solution. So, I wanted to share this experience, which, of course, will continue over time, and which will allow us, I hope, to install electrophysiology in Ethiopia sustainably. Thank you for your attention. Thank you, Dr. Christina and Dr. Felix, for letting me introduce a close friend of mine, a senior consultant electrophysiologist from Egypt. Dr. Alfie is very known in Africa because of his regular visits to treat patients in Tanzania, in Kenya, Nairobi, and Mombasa, in Nigeria. He does regular visits to Africa to do a lot of ablation procedures, CRT and pacemaker implantation. And Dr. Alfie's effort in Africa is very well known, and I'm very happy to introduce him to share his insight in a patient of Wolf Parkinson's Ablation. Thank you, my dear brother, Dr. Salah. And we are happy and actually sad in the same moment that you left Egypt and you are now in Tennessee, but I hope you all the best. It's my honor to present the ECG tracing for fellows, but I see no fellows. So maybe I'm the fellow. Yeah, okay. Okay. I will go fast because we have to catch time. This is a 32-year-old female with no past medical history and presented with palpitation. The question was, what the diagnosis? It was a Libyan patient coming to Egypt with this tachycardia, and actually she flied all the way with this tachycardia. It was incessant. And anyone wants to interact? Okay. So actually this patient, we diagnosed her as an atrial flutter, atrial tach, and we did a transesophageal equity OE, and we found that she has a left atrial appendage aneurysm, and she underwent surgical incision for this aneurysm, and the tachycardia now stopped. And this, the thing is that you can treat the arrhythmia surgically. So this patient was treated by surgical incision. Okay. The second patient is a 60-years-old patient with a single-chamber ICD and ischemic cardiomyopathy presented with this palpitation. Anyone wants to share? Yeah, please. Okay. And if you can, I want laser pointer. Yeah. What about this? He has a single-chamber ICD, and this patient was in the CCU, and actually this 12-lead ECG was taken while the device, the ICD was given an anti-tachycardia pacing. And the thing is that there was doubt of his tachycardia, whether it is like pre-excited atrial fibrillation, it's a V-tach, but we made the diagnosis that it was an irregular ventricular tachycardia. And at the end, there was a start of the other ATP, the last beat. So this is an ATP from the ICD, and it is irregular ventricular tachycardia. Okay. This is an apparently healthy 28-years-old male with no history of syncope, normal ECU, normal resting ECG. He had some palpitations, and he did this Holter monitor. What about this Holter monitor? Should you implant a pacemaker for this patient or not? Yes, actually, it was in the, he was asleep, and it was high vagal tone, and the patient never had syncope, and we decided not to implant a pacemaker for this patient. Okay, next patient is a female, aged 14-years-old, with a structural normal presenting to the ER with these palpitations. What do you think? Anyone want to comment? Share. No, it was a structurally normal heart, Dr. Ghalia, yeah. Yeah, actually this patient has this right bundle tachycardia with left axis deviation and actually we did an EP study for her and it was a fascicular ventricular tachycardia. Okay, next patient was a young boy, he was a five years old boy with history of surgical repair of Tetralogy of Fallot and presented to the outpatient clinic for evaluation and actually was referred for ventricular tachycardia ablation. What do you think about this? Yeah, yeah, this is correct. It was an atrial flutter and it was ablated, I think, from the cave of tricuspid isthmus. Yeah, Prof. Mervet is saying that it's a cave of tricuspid isthmus. Okay, next patient, I hope, yeah, Brian. That was done in Egypt. I don't remember the operator, but it was done in Egypt. It was a patient done in Egypt. So if you would comment, Brian, on this. Yeah, it was very deep septal but I think not a left bundle area pacing but it was very deep septal and actually we were very happy that it was that narrow and we wished that we could have the typical left bundle area pacing but it was very deep and the patient is doing fine. Next patient is 46 years old, presenting with dyspalpitation. What do you think? Yeah. Correct. Correct. It's the most easy one. It was an atrial flutter and that was successfully ablated. And next patient is 82 years old with ischemic cardiomyopathy and the CRTD implanted in 2015 and he was in cardiogenic shock in the coronary care unit. What do you think about this ECG? Yeah, correct. It was a slow VT. Yeah, yeah. Actually he had VT for a long time and this patient he passed away in the coronary care unit. Yeah. This the last slide for me, no I think it's before the last one. It's a 40 years old male and he has his ECG at rest. What do you think about this? Okay, this is his tachycardia. Yeah, yeah, it's a mahaim tachycardia and this patient was ablated at the postulateral right postulateral region with mahaim fibers and it was typical mahaim tachycardia. Thanks for everything and I hope Salah will join us back in Egypt. Thanks for everything, it was an honor. Good afternoon everyone. I'm Dr. Joeli from Tunisia. I want to thank AFRA President and Vice President for this wonderful opportunity for African cardiologists to present their cases during this wonderful and great Africa Summit and in a great fashion in the States. So thank you for having me. I'm about to present a clinical arrhythmia risk management case subtitled Is this a coincidental or consequential association? I have nothing relevant to disclose. This is about a 42-year-old male, no medical or surgical history, no cardiovascular risk factors, occasional cigarette smoking, he came for chest pain, fever and chemical symptoms. Temperature was at 38.3 degrees Celsius without any acute heart failure or poor hemodynamic status signs. The test revealed a high CRP and troponin levels and with negative COVID-19 tests. Let's see perpignic ECG. This is perpignic ECG and as you can see here, it's sinus rhythm, regular sinus rhythm, an abnormal, slightly abnormal STD complex in almost every lead. But let's look at right precordialism, especially in lead V2. There is a more than two millimeter high takeoff COVID ST segment elevation, right precordialism, and this is followed actually by a rectilinear downsloping ST and negative T wave without isoelectric line between the T and the G wave. So this is perpignic type 1 Brugada ECG. Couple of hours later, here is the ECG. As you can see here, there is horizontal ST segment elevation and lateral and posterior leads, and also there is a subtle ST depression in the BR. So it's a fever of isthemia or acute myocarditis. Let's see the V2 and V1. There is V2 and as you can see here, there is the same high takeoff, more than two millimeter high takeoff elevation, but here with the concave downsloping ST and the negative T wave with a slight isoelectric line between the two. It's slightly different morphology, but still has the pattern of type 1 Brugada ECG pattern. Right now, we have criteria for staining myocarditis and Brugada syndrome. TTP didn't show any abnormal segmental motion abnormalities, and the urgent coronary angiography didn't show any abnormal stenosis or thrombosis. So we didn't have suspects in these cases is acute myocarditis. So we did the cardiac MRI 24-36 hours later, and here is the cardiac MRI look video showing normal motion abnormalities, normal lymph ventricle size and function, and lymph ventricle ejection fraction was at 57. Here is the late acquisitions showing late gadolinium enhancement sub-epicardially in inferior and lateral lymph ventricular walls with signs of acute inflammatory edema failing acute myocarditis. We basically received ACE limiters, beta-blockers, and COSHC from the second day and routine follow-up after the third workshop. But what about the type 1 Brugada ECG pattern? Let's see what happened. This is the 12-lead ECG on day 2, and here is negative or flat T-wave in almost all the bleeds with the T-wave normalization in the VR and the low amplitude QRS in late 1 and LVR. And here is V2, and as you can see here, there is a high type of air purulent, more than two moments of elevation with a convex ST elevation on the blue arrow, and on the green arrow, here is the positive T-wave. So this is Brugada type 2 ECG pattern, saddleback pattern. On the fifth day, there is normalization of right precordial leads with persistence of negative T-wave lateral leads. One month later, the 12-lead ECG showed the complete normalization of the right precordial lateral leads, and the halter also didn't show any arrhythmia or dynamic Brugada ECG pattern. So is this a coincidental or consequential association? It's worth noting that despite the persistence of fever and before receiving any treatment, the type 1 didn't appear since ER and first day visualization. And this case is in favor of phenocopy rather than syndrome. Why? Because of three things, the low protest probability that there were no symptoms, no history of syncope or arrhythmia, no family history of subcardiac death, arrhythmia, or congenital cardiac disease. The presence of identifiable acute and reliant condition, and the resolution of the ECG pattern with myocarditis and urine remission. So this phenocopy is very rare, but the distinction between the phenocopy and the syndrome lies mainly on three affirmational criteria, and this is very important because the ECG patterns are usually identical and disjunctable. So these three criteria are really very important for distinction. For the provocative tests are highly advisable but not mandatory, especially in surgical right ventricular outflow tract manipulation. These tests are not mandatory because of the mutation, which is identifiable only in 20-30% of programs. So take into account the acute phase of myocarditis, the absence of ILB, so the optional blocker to perform the test, low protest probability, the resolution of the ECG pattern, and the normal listening ECG and halter after one month. So the test wasn't performed and we can classify the phenocopy as type 1 class B Brugada phenocopy case according to Goldschalk and Hansen. This myocarditis-induced Brugada phenocopy at unknown is very rare, but nevertheless the absence of CMR signs of RVOT inflammation made us wonder, is it the fever or the myocardial inflammation responsible for the Brugada ECG pattern? But what's interesting is the rapid appearance of the type 1 ECG pattern even before the lateral and posterior STL vision, and there is peculiar progressive step-by-step resolution of the pattern from type 1 to slightly different type 1 and type 2, then to normal. So this peculiar step-by-step recovery continued despite the fever, which persisted into the fifth day of hospitalization, and also despite the beta blockers, which can slow the slow of the sodium and work for it. So also maybe this peculiar step-by-step recovery, maybe it's favoring the depolarization theory more than the repolarization theory, because of the possible progressive resolution of the contactive block along the gradual decline in the myocardial inflammation. Is this a high risk of sudden death? It remains unclear, but since the underlying cause of the phenocopy, the anaphylactron and the pathoresiological mechanism, we believe that it has also a critical role in the outcome of this pitch. The major limitation of this case is the absence of relative practice. Also, the fever may induce artificially a Brugada ECG pattern without any genetic predisposition and in a low pre-test probability clinical setting. Also, unfortunately, we don't know the exact site of placement of right fecundia leads in the first two ECGs because they were performed outside our department, but we believe that they are at the third intercostal space, just like the rest of the cohort. The main learning points are just myocarditis, phenocopy, Brugada case, Israel, and myocardial inflammation play an important role, especially in the first hours. And this peculiar step-by-step progressive resolution of the ECG pattern that continues despite the presence of fever and beta-blockers may be favoring the depolarization theory. So I want to finish with this question. Is it the myocardial inflammation or the fever responsible for the Brugada pattern? So these are my references and thank you very much. Good afternoon. I would like to thank HRF and AFRA for organizing this summit and also for this kind invitation for us to be sharing with you what has been our practice in Angola. I divided this presentation in two parts. First of all, we would like to share with you some broad data of our country for you to better understand our context of work and then present you our project to initiate and maintain regular activity of an arrhythmia unit focused on assistance, education, and resource. As you know, we are located in southwestern African coast. We are 34 million, of which 56 under 18 years old. Our economy is characterized mainly by the exploration of natural resources and oil. Our GDP is about $90 million, of which 2.4% were allocated to health expenditure last year. Our hospital is located in Luanda. We started activity in 2008. Our cardiovascular department serves a population of about 100,000 people. We have a cardiology ward, non-invasive outpatient unit, a PCI unit, and a cardiothoracic surgery service. Our workforce, excluding the surgery service, our workforce comprises 32 allied professionals. We are 15 cardiologists, of which 10 are women. We have three subspecialties. This is broadly our main activity per year. Our cardiology residency takes usually five years, and most of the colleagues that do the subspecialty training do it abroad. We plan to initiate the electrophysiology activity. We are currently renovating our structure, and we plan to develop local expertise with on-job training, proctors, and also with training abroad. These slides were just to show you where we are currently and what has been our practice over the last 16 years. We will now show you our projects to incorporate the electrophysiology activity in the activities we are currently performing. The project of the creation of the unit has three pillars, namely assistance, education, and research. These are our main goals. Those marked with the green star are the activity we are currently performing. We intend to improve this activity, but our main short-term goal is to incorporate the electrophysiology activity in these activities and also initiate a prospective registry of our activity. As I told you, we are currently renovating our infrastructure, and hopefully soon we will have our EP lab. While doing that, we are facing some major constraints. Most of them were already mentioned by the colleagues that came before me, and I will not stress too much about this for now. Our main motivations are these here presented. We think that although we have many challenges, we don't have a structure organized, but it is still feasible to initiate the activity. For sure, we will need help from our colleagues abroad in our country, but we are motivated to initiate the activity. Thank you very much. I finish with this image of our city. Thank you so much, Dr. Segade, for inviting me to be here today, and thank you for allowing me to speak on this topic. I don't want to be one of those Americans that just talks about American things, but I think it's important to talk about U.S. trainees so we can talk about how to motivate the next generation of trainees to build these collaborations. So I'm going to talk a little bit about the opportunities that currently exist for trainees in the U.S. So currently, if you are a trainee within the U.S., the opportunities for global health are varied. When you start early in your training, you can start with medical school rotations. Some universities offer this. They're typically six- to eight-week rotations, and it's typically for the learner in that environment primarily. If this learner is very motivated, they can apply for grants and fellowships that allow them to take a break in their training, usually for systems or policy or research-based work in between medical school and later training. In residency for internal medicine, there are opportunities at specific programs where you can do a global health pathway. So that allows for some of the faculty to be involved in education and also builds in time for those people to go abroad at partnering institutions to start building these relationships and experiences for their future careers. After this, I have global surgical fellowships listed there, but you won't see any of the faculty that are here at HRS participating in those because they're true surgical fellowships. There's no EP or cardiology faculty in those, and so if you are interested in those, you need to be self-motivated to continue a career in global cardiology or global EP. So some of these issues that happen along these trainings is that, as I was saying, they're mostly for the learner, so there's no opportunity for longitudinal involvement to go back and serve that same community that you were once serving. Often there's limited funding for these, and they're mostly self-funded by the learner, and because of that, it's really prohibitive for people who might otherwise be motivated but can't produce these funds on their own. And also many of the opportunities that exist are unfortunately not modeling the sustainable solutions that many of our colleagues have talked about here today. So why am I up here talking about this? I had the specific opportunities to work in some of these settings, and I had the unique opportunity to work at Ampath Kenya. Now this is a really beautiful collaboration between the government of Kenya, the Ampath Consortium, which is a multiple universities that are all members of the consortium, and as well as the Moi Teaching and Referring Hospital, which is a large encashment hospital in Kenya. And so they've really built a lot of infrastructure in the region, which was at first motivated by the AIDS epidemic, but now they have a cardiac ICU unit there as well, and they're working on building their EP infrastructure. So I worked there as a resident for three months and worked with the registrars there alongside them, helped lead the teams, and we had a lot of learning that happened during that period of time. And I really wanted to continue to work at this hospital, but opportunities to do that were quite limited. I was lucky that my own institution supported my own self-motivated work and I returned as a general cardiology fellow. Sorry, we have slides moving on their own. And I was able to return as a general cardiology fellow to continue that relationship. But I think I personally faced a lot of hurdles in trying to build this career. And I think what we could do here at organizations like this one is really try and break down those hurdles to be able to build these collaborations. So I think the first thing that we could do is really centralize access to the opportunities that live out there. Some people have talked about that today. If we had a central database in which somebody who's motivated to participate in global collaborations, they can simply turn to that database to find what opportunities exist. The other thing is to work on funding from national organizations like this one to allow for fellows who are motivated to be able to do these programs because otherwise we're creating a lot of financial barriers for otherwise for people who would otherwise be trying to do this good work. And lastly, I think that I've been so lucky to have mentors that are here in this room who have helped me sort of navigate this process and to continue to build my career, but not everyone has that opportunity. And I think that it would be great if we could work on formalizing mentorship programs to allow faculty that we have here to work with trainees to build that. Thank you so much. Thank you. Well, I have two disclosures. One, I was not born in Africa and two, I'm not Matthew Sackett, but Matthew, Dr. Sackett could not be here today. These are his slides. He really has been a pioneer in working with Dr. Gandhi. You heard from earlier in doing EP work in Tanzania. I was lucky enough to go to Tanzania last year and work with Dr. Gandhi and his staff. So I'll be presenting Dr. Sackett's material today. We've heard a lot of really amazing things today. If nothing else, what's happened today is just to showcase just how much amazing work is being done throughout Africa. Let's see here. Okay. You know, I think in thinking about missions and I think both Dr. Sackett and I agree that we probably wanna move away from the term mission, but for the purposes of just common parlance, we'll use it in this presentation. There's really two types of missions or collaborations. One, where you kind of go into a place and there may be limited availability of services and someone might have a specialty or a skill and you do some stuff and then you leave. The train it forward model, which we've heard a lot about today is really about building sustainability in various countries. And it requires partnership with local physicians, local healthcare providers, local governments, local hospitals to ensure that sustainability can occur. And the goal is really to help facilitate a situation and infrastructure so that local practitioners can do these kinds of procedures independently. Obviously with EP, which is a very technology oriented field, a lot of expensive equipment, it does pose some challenges. Just talking a little bit about the organization Madakari, which was started by a neurosurgeon many years ago, Dr. Sackett and others have sort of led the EP realm for this nonprofit. It's an NGO and they've really focused on the train it forward model in Tanzania. The former president of Tanzania was basically bothered by the fact that many of his countrymen and women could not get cardiac services in Tanzania. And he earmarked a great deal of money to form the JKCI, which is a cardiac institute that houses many cardiologists. So this was the development of the JKCI and in Dar es Salaam, Tanzania, Dr. Gandhi and some of the other speakers are a part of this effort. And the idea was to create a sustainable model where practitioners with expertise from different parts of the world, including the United States could go to the center, work with local physicians and build a local infrastructure in this case for EP. They started with having to build a cath lab. There was no cath lab there. So a cath lab was built and they had the funds to do that. And if you look at the numbers of coronary angiograms and other percutaneous procedures that has grown over the years, between the years 2015 and 2020, approximately 3000 coronary angiograms were done. Most of these angiograms are now being done by local physicians in Dar es Salaam. And that was done in large part with training from physicians in the United States and elsewhere, Egypt, China as well. One of the big consequences of this is the monies that were being spent sending patients from Tanzania to other countries to get services was now basically we're seeing a tremendous reduction in cost. And it was estimated that about $30 million was saved, US dollars was saved by implementing this institute and doing these services locally. So I'll just talk very briefly because I know it's been a long day, but I do wanna share about some of the EP stories and journeys that we've had. 2016, Dr. Valentine began by proctoring for some pacemakers with a one week EP camp. We refer to these sort of sessions in Dar es Salaam as camps. They're usually about five days long. And then Dr. Saket began proctoring ICD, including CRT. You know, Dr. Gandhi has been doing CRT patients on his own now. And then in 2019, there were three trips with a number of different people from different parts of the United States. And in 2022, the Carter system was acquired so they would be able to start doing some basic mapping. Dr. Gandhi was trained in Egypt and in China. And we've just continued to work closely with him as he's evolved as a really outstanding operator. In 2023, Dr. Saket went back to do some ablations. Now with Carter, they actually do have mappers that can cover the cases from Dubai or other places. And that's been a really big development in our ability to do more complex cases. And in 2023, I had the privilege of going with Dr. Bhadwar, one of my colleagues. We did 21 cases in five days. Dr. Gandhi scrubbed in all of those cases and we managed to accomplish quite a bit. In 2024, we're really excited. Dr. Bhadwar attended a conference that was put on by JKCI and did some cases. In July, Dr. Saket is gonna be going back and doing some cases along with Dr. Omotoya, who spoke earlier, or actually asked a question earlier and I think is speaking later today. And in July, actually after HRS, Dr. Gandhi is gonna be coming to Honolulu to spend two weeks with me and two weeks with Dr. Bhadwar. So we're really looking at different models, different ways of trying to work with local providers to give them the expertise that they need to carry out on these procedures independently. And then I'll be going with Dr. Bhadwar back to Dar es Salaam in September. My job will probably fire me because I'm never around anymore. I'm always just traveling around to different labs around the world, but it's really truly inspirational. So just real quickly, the planning for this actually requires a lot, four to six months in advance. We've been able to get Medtronic to donate devices, other companies to donate devices. Medtronic actually has sent reps and paid for reps to come. They're actually as important as the EPs that are there because they've trained the staff at JKCI to do device interrogation. So it's really a team effort and a really wonderful experience overall. Typically we'll do about a week. And like I said, their long days is usually five to seven cases per day. So obviously I think you've heard a lot about the challenges. Every country in Africa clearly is different and has unique opportunities and challenges. Tanzania, it seems to me, is poised to be a leader in this region. They have outstanding providers there and it's been really wonderful to be a part of that effort. This just sort of outlines the trends in terms of different cases that have been done. And you can see over the years, more and more cases are being done by the staff at JKCI. So we're always looking for help if you're interested in getting involved. Dr. Saket has his email up here and you can use the QR code that will take you to the website for Badakari. And thanks again for staying for such a great session. I really appreciate it. I know it's been a long day, but thank you for your patience. Sam Omotoi, I'm of Nigerian descent, but trained here at Cleveland Clinic where I was a fellow, finished and then came back, being on staff and now the director of electrophysiology in the region. Briefly, I would like to talk about the role of medical missions in Africa from a Nigerian perspective. I would not take much of your time, but I'll give you a background. I know we've talked about this a lot, but Nigeria is the largest black nation in the world. So 200 million people in the Western segment of the African panhandle. However, 60,000 Nigerians still spend over $25,000 per year per trip in medical tourism to seek quality care abroad. That's about 1.5 billion per year. These costs are usually mostly out of pocket. And of course, additional costs for social support and stays and so on also contributes. In terms of healthcare expenditure per capita in Nigeria is very, very small. It's about $70 per person per year, which is about 3% of GDP compared to $14,000 in the US and about 550 in South Africa. But most importantly, if you look at this graph on World Bank, for the first 25 to 30 years post-independence in 1960, the healthcare expenditure was actually zero. And then it rose up and then bounced around a little bit. And now it's back to zero by the last three years. We've kind of highlighted Dr. Muzaha's slide, not gonna belabor it, but a few things I wanted to point out in this slide and this paper is that, just like every other part of Africa, Nigeria is no exception in terms of how rudimentary EP service line is. Not only that, but also all the convoluted problems that exist, lack of local expertise and infrastructure, many anti-epidemics are not registered or available. The monitoring of anti-epidemics, such as Imodoro, for example, can be challenging. A small number of cardiac EP docs in Africa, as we've mentioned. And of course, most importantly, is access to EP care in Nigeria. Based on that, I co-founded a 501c3 with a non-EP person, actually, that I respected very well, called Nigerian American Medical Foundation, which is kind of a diaspora organization with aim to restore and retain medical subspecialty. It was a very lofty goal, really, not only EP, but every other subspecialty locally in Nigeria which kind of using teleconsultation and second opinion and expert opinion platform to make these services locally visible and accessible to patients. And also kind of establishing agreement with purpose-built tertiary centers to deliver subspecialty care regularly, but locally. We're able to secure an example of this kind of collaboration with a purpose-built hospital in Nigeria, in Lagos, called Evacare. And it's actually one of the Evacare group that exists globally, both in Pakistan, Kenya, and Nigeria, and many other places. And by doing that, we're able to have a few sessions of teleconsultation. This is just an example of a consultation that I did with actually a U.S.-trained cardiologist back in Lagos and myself back here in the U.S., where I was providing some expert opinion virtually to kind of address some of the EP issues that the patients had. So my aspirational outlook and aspirational outlook beyond this is that we'll be able to develop a framework for integrated cardiac EP service in Nigeria using purpose-built tertiary facilities like this to serve as local access points and also to create local, sustainable, integrated cardiac EP service line, and to also invigorate all the industrial collaborations and relationships that we currently have, as in this room and elsewhere, and kind of make a business case to increase growth and communal access to EP care locally in Nigeria. And most importantly, as we kind of, as I pointed out a question about the role of medical missions in Africa and Nigeria, the answer I could come up with was that I hope that medical missions would just be harbinger rather than the mainstay of comprehensive EP ecosystem in Nigeria. I would like to finish by acknowledging and honoring this co-founder who actually just passed away a few months ago, to say that the great use of life is to spend it for something that will outlast it. Thank you very much. Good afternoon, everybody. It's my pleasure again to present this very critical subject, which is the women in Africa in the field of electrophysiology. This is me, Dr. Mervat in the scrubsuit and Dr. Gheda who conducted this research with me. Historically, women have been under-presented in various medical fields, and so in cardiology and specifically in electrophysiology, this disparity extends into leadership roles signaling a broader issue of gender inequality within the medical community. Our study is positioned to address this gap focusing on the African continent where data is particularly scarce. Our primary aim is to uncover the specific challenges faced by female electrophysiologists in Africa. Through this, we aspire to illuminate the hurdles, the hurdles, aspirations, and needs of this profession, providing a foundation for a rational and actionable change and greater gender equality in this field. This study was a comprehensive survey which was administered to African women working in the field of electrophysiology. The survey covered various topics including basic demographic data, work environment, radiation safety, work-life balance, and discrimination. The survey was distributed digitally and made anonymous using this Google form. All women agreed to participate in and have their data collected for research purpose. We were lucky to have 54 EP professionals from 33 African countries. 70% of those were from my country, Egypt. These 54 electrophysiology professionals, their age ranged between 25 to more than 60. I'm 65. Mostly age between 41 to 50 years, as we can see in this diagram. 85 of women are actively practicing. However, 15 will have temporarily stopped the profession. The experience level vary from 46 having less than five years of experience. 48% had fewer than 50 procedures per year, which is very low. 64% who answered the survey were calling for leadership development program. 78% of respondents expressing a high demand for female-focused networking. The challenges and the hurdles, work-life balance, emotional stress and burnout, radiation safety concern, and gender stereotyping. In this survey, we got the biggest challenges in the EP career was work-life balance, 44%. Radiation exposure concern, 25%. Lack of female model and mentor, 9.6%. Discrimination, 7.7%. And other factors as you can read. Work-life balance, radiation safety concern, lack of female mentors were the main challenges facing women in this survey. Work-life balance, 43%. Radiation safety, 25%. Lack of female mentor, 9%. Burnout phenomena was experienced among EP professional and I'm one of them. Yes, and my fellows are the reason for this. They keep pushing me, pushing me. Yes, Anna, you were with me. Yes, Brian, you saw that. Yes, we have witness here. High workload, emotional stress was burnout in over 76 of women. Gender stereotyping and discrimination. Gender stereotyping experienced in the elective surgery workplace was really answered by 29% experienced it. 17 said never experienced and 5 were afraid to say. 45% impacting career growth. Percentage of respondents by impact gender stereotyping on professional growth. They said that this happened and that was impacted on their career growth in 45% and no impact 56%. Shaping the future and this is what we want to do. Inclusive policies. Implementing more inclusive policies and practice is a crucial first step in addressing the challenges faced by women. Mentorship and networking and this is why you are here. Fostering supportive network of female role models and mentors as well as providing targeted mentorship programs and opportunities for female focused networking can help empower and encourage more women to pursue career in the field of electrophysiology. Radiation safety education. Enhancing radiation safety training and implementing better safety practice can help alleviate the significant concern around radiation exposure and its potential impact on reproductive health, a major source of stress and anxiety for all female electrophysiologists. Leadership development. Investing in leadership development programs specifically designed for female EP can help equip them with the skills, confidence, and support needed to overcome barriers and reach position of influence within the field. Because I am the last one, we have to enjoy this film. Yes, we are African. Thank you. We're going to have a short panel discussion, and Dr. Eduardo Saad and Professor Mabat will give closing remarks. So we have a short panel discussion, and Dr. Keba is here, Samu Motoi is still in the audience, and I don't know if there are any specific questions for the panelists. My question goes to Professor David concerning the pediatric formation, the pediatric cardiology formation in Rwanda. Is it a course only for, a course, it's a different specialization, mainly only pediatric cardiology, or is it added to general cardiology? And the second question is, is there a window for other foreigners, I don't know, from Cameroon, from other countries, to come to Rwanda for the formation? Thank you for the questions, very much. So to the first one, the entry specification for the fellowship is to completion of a residency in pediatrics. So it is really a pediatric-focused training, and in Rwanda, the dividing line between pediatric and adult care is usually 16, so a little bit younger than in the U.S. and Europe. It would be open to a foreign candidate, although I know that the focus has been on expansion of the Rwandan workforce, but I think that they would accept a foreign candidate, I think that would be worth discussing. And the second question is to E.P. Moda, concerning female and E.P. Moda, I'm asking, my question is, men, we don't complain if they are not female in the field? That project, because, and again, there are some that cannot perform, or they're not able to perform five, more than five procedures per year, or per month, I don't know, I don't know how well. We men, we are not, we are doing it very well. Sorry, Professor Malvat is busy responding to WhatsApp. I think Cabral will frame his questions. I don't know what the, how to summarize it, but say it yourself. We men, we are not complaining if there are no females in the fields. Like this presentation that you had concerning female and their problems in the E.P. We are not talking about men in the field of elective surgery, we are talking about men at home. This is the main problem. So, and also the culture of the society in Africa. I didn't want to show you the questions, because if you see the questions, you will cry. Because women, I sat down with many of them, and we wrote down what we really feel. It's inhuman, it's very oppressing for women, it's very challenging, and it's very unfair. In our culture, in the Middle East, women do everything. In other African countries, yes. So when we publish this paper, I think 80% who answered it will be divorced, because they said the truth. We hope that we get good chance at work for E.P., and also some mercy for the women who have the responsibilities at home. Home duties, children, men duties. Men, when they marry, they think that their wives should do everything for them. And when they do little things, they think they are sacrificing their time, effort, money. And the thing is, I allow you to go to work to get money, give me this money. These questions are in the survey, and we are going to publish every single question, because this is reality. No one touched this before. So we have men at work, we have men at home, and we have sometimes a driver who is a man, and if you talk to him in a bad mood, he can leave you. We have fellows, but we are struggling, and we are competing. And because we tolerate nine months of a human being inside our body, and we are happy, this is why we can tolerate all of them. I appreciate the scientific answer from Professor Marvin. I will also frame a quick question to two fellows on the stage before we go on to another question about how do you foresee U.S. trainees in electrophysiology, how to collaborate with trainees in Africa, and I'm just talking mainly about the role of Global AP. David has an opportunity through sabbatical with Fulbright, but I would like to hear from Dr. Mazuray and Dr. Garg to respond to that. Thank you so much. Thank you so much, Dr. Sugade, for the invitation. And thank you so much, everyone, for being here and listening. My name is Kenneth Mazuray. I'm currently a second-year general cardiology fellow at Yale New Haven Hospital, and to be honest, when I started training, I didn't know too much about EP, and I kind of had an imaging focus, but then I did the rotations. The science was very exciting to me, and I'm basically going to be applying this year. But I think what also drew me to this specialty was the severe disparity in services, EP services in the developed world and in the developing world, particularly in Africa, particularly in my home country of Nigeria. And I've been working with Dr. Ernest Madu for more than a decade now. So Dr. Ernest Madu established the Heart Institute of the Caribbean with his partners around 2008. And they've been running this hospital in Kingston, Jamaica, which is more of a low-middle-income country, and they've successfully shown that you could run a full-service cardiac hospital, you know, CAT lab, cardiac ICU, cardiothoracic surgery, with an efficient mindset that is not reliant on charity. And the idea that Africans don't have a lot of capacity to do this, you know, it's really saddening to me. And I think that's one of the reasons I want to do EP now. And so I'm hoping in the future we can establish the systems. You know, I come from Nigeria. Yes, Nigeria has, you know, it's a lot of people, but I can tell you there's a huge middle class, and people really need these services, and people are willing to pay for these services. And, you know, a lot of the pricing in the West, I think, is, you know, to be honest, it's inflated. You know, we face that here in America. But again, we can get subsidized services in Africa that can help us run efficient hospitals. And sorry, that's beside the point of the question that Dr. Shogady asked. But I wanted to come back to the issue of trainees. So I think, you know, just like my colleague, Dr. Garg said, is a lot of self-motivation. So for example, I started a training program, I told my program director, look, I need to do an elective, you know, somewhere, you know, during my training. And thankfully, he made it happen. So I'll be going down to Jamaica for a few months in January. My hope in that elective will be to, you know, experience the pathology we see in developing countries. And also to start doing some research as to what's the burden of disease, again, because one of the problems we have is that there's no data. And so it's harder for you to go to, you know, to get grant funding, for example, to study disease in the developing world. So I think, you know, I agree that it's an issue of there's a lot of self-motivation. And then I'm also going to really try and connect with some of our colleagues that have been able to sort of carve a path in that career where they actually, you know, are able to spend half of their time maybe in the US or in Europe, and half of their time in a developing country building the systems. And one of my, you know, even though I haven't met him yet, but I'm trying to get connected to him is Jerry Bloomfield, who, you know, actually had a career development award from Duke and was able to spend five years in Kenya and still spends a lot of time there, but intermittently. And I think that was very commendable. So I think, you know, I agree, it's a self-motivated pathway, there's no formula right now. And some of us are really interested, we want to really help. I think on that same note, I would just say that I actually feel most protected as a trainee right now at an institution that's willing to support my work. I think what scares me is what happens next when you go out into the world on your own, whether that's in an academic center or at a more private center, the question is always going to be, but who's going to fund your time? And so I think that'll be a really interesting problem to solve, you know, as we move out in the world. And that's why I think, you know, talking about mentorship for people who have done it before is going to be really crucial. So I thank everyone here for being supportive of us as trainees as well. Hi, my name is AJ Hale. I'm from the Dennis and Jane Rees Foundation. First, Dr. Shogunay, I appreciate you stepping in because I thought I was going to follow Dr. Murvat for the second time in like two weeks, which is always tough because it's fantastic to hear you speak, honestly. So I just want to come up here and just make a quick comment. I think this is amazing having everyone together. And you know, we work very closely with Your Heart and the Cardiovascular Education Foundation and other organizations working to build capacity sustainably. So all that I ask is, you know, if I haven't met you already, if you haven't been introduced to our collaborative, please come by and have a chat with us because we're looking for more organizations and more dedicated individuals to join. We do offer some degree of sponsorship. If it fits into what our mission is trying to accomplish in those specific cases, just keep it up. And I'm so excited to be a part of all this and really excited for the next AFRA events in Rwanda because that's my second home and we're excited to sponsor that and hopefully cover some people to join it. So thank you very much. Thank you. I'm Dr. Agundungu E.P. from DMV from D.C. I know Dr. Shagede, we went to the same medical school and his wife is my best friend. But anyway, I'm part of Cardiovascular Education Foundation. And I think something that HRS or AFRA has to take note of is that the training in parts of the world like Nigeria is very different. So currently I've made like at least 10 trips to Nigeria and we teach people how to do devices and we've started a new ablation program for Dr. Ekeru. But we're teaching actually attending physicians. So it's a little bit different from where you talk about fellows. We don't really have fellows. We have junior registrars, senior registrars, but then we have attendants who have spent time in India doing interventional work and are the best people that we can impact some device implant training to. So it's a little bit different. So if we're talking about growing something sustainable, I was very interested actually when I heard about what you can do with robotic EP because in a country with 200 million people, you conceivably can actually have a situation where you can have that lab completely busy all year around because the problem is you train people, you come back in three months and you taught them how to get first rib approach access, but they've forgotten because there's just no volume. You know, EP is a specialty where you have to keep doing it all the time. So that's the challenge we're facing, trying to build a sustainable program where the people that are being trained have enough volume or have access to come out and do it. And even if they travel and they do it in the US, if you come back to Nigeria and you can do that procedure for three months, you lose the skill. So that's the challenge that we face trying to impact something sustainable outside the US. So just a comment. Thank you. Thank you so much. I think on behalf of the Rhythm Society and the global committee, this was an amazing session of four hours duration. Congratulations to everyone that actually completed the marathon here. Thank you, Cristina. She made a real effort to be here today too. So thank you so much for all your input and effort and for staying here all afternoon. So I hope that this, we come out of this, you know, with different ideas, stronger and trying to face the real problems that the continent faces in a more straightforward and at least with different ideas and different motivation to make things better. So on behalf of HRS, again, thank you very much for coming. It was a great session. Thank you, HRS, for giving us this golden chance. Next year, we'll have one center in every African country specialized in device and EP run by their own fellows. This is a promise. Felix and I are working on this with the fellows. We started our training online, EP and devices and allied professional. And next year, they will present from their own labs here. Thank you all for waiting.

cardiac electrophysiology education

African summit on heart rhythm 2024

mobile EP labs

remote navigation systems

underserved populations

structured EP education programs

healthcare professionals training

diagnosis and treatment pathways

collaboration between stakeholders

Rwanda EP services

South Africa EP services

political will

infrastructure development

workforce expansion

training programs