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Latin American Summit 2023 - Portuguese Closed Cap ...
Latin American Summit - Portuguese CC
Latin American Summit - Portuguese CC
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I think it's about time for us to start so I'm going to start. I am Jody Hurwitz. I am president-elect of the Heart Rhythm Society and it gives me incredible great pleasure to welcome you all to the Latin American Summit of 2023, a combination between HRS and LAHRS. This is actually the second year we've been doing this summit. You all be delighted to know that last year we did not have anywhere near the showing that we have today so it's really great that you all can be here in person and that I understand that there's a tremendous number of people on Zoom who have sent in videos to discuss this. This really marks a new chapter I think in global relations between HRS and these organizations, especially how important to us LAHRS is. I think that we look forward to really hearing quite a lot about what's going on all over with all of the different organizations and countries. I think this is incredibly fascinating. I think I'll have everybody here introduce themselves and welcome and we're delighted to have you here in New Orleans. Welcome to HRS 2023. Thank you, Jody. As you heard from our president-elect, I'm Dr. DiBiase and I'm the chair of the Global Relations Committee and it's a pleasure for me to have organized this together with all the involved parties for the Latin America Summit 2023. This is a way to connect Latin America to the Harlem Society. We hope we can be a resource for you at any level that we're going to discuss today from education to economic business and many more. I thank all the partners and all the presidents of Latin America, HRS, and each other society OVP of the Latin America for being here today either in person or as we heard many people are on Zoom. So thank you very much and I give the words to the president of LHRS and to Marshall that actually probably just finishes his term. Marshall is the last president. Yes, he's just finishing. Okay, thank you very much for this invitation. We started almost a year ago to prepare this summit and I am very thrilled to be here today with you, my friends, and those who could not attend in person having online. I think it's very important for us, for our region, to have this kind of meeting, to know the things that we could do better and I'm sure that HRS will help us, will help our regions and, oh, by the way, I'm Marcio Figueiredo from Brazil, LHRS past president. Okay, well, hello everyone. I'm Dr. Lizar Rojel from Mexico. I'm a Latin American Heart Rhythm Society current president. Welcome to this Latin American Summit 2023 organized together with HRS. It's a pleasure to be here with you. In this summit, it's exciting to see electrophysiologists from different countries of Latin America. This summit is part of an initiative to find the EP world community and strengthen the relationship between regional societies. This event will unite EP experts from Latin America to trigger awareness and face challenges in health, politics, and our region. During two discussion panels and several presentations, you will learn about the most common disease in Latin America, but also you will see the development of cardiac electrophysiologists in different Latin countries, what the current situation is, and limitation and expectation. This summit is a great opportunity to understand our reality, our possibilities, and our limitation, but also it's a great opportunity to identify similarities and differences between us to develop strategies and politics that help us to improve the EP in our region. I want to thank the summit organizer, the HRS authorities, and especially Dr. Néstor López-Camanillas for his enthusiasm in this project. Thank you. Néstor? Just to say thanks to HRS for the opportunity to the EPs from Latin America that are present or maybe virtual, and for the industry people that are here, and it's a huge thanks a lot for everybody. And I think it's a moment to start, and then maybe I can introduce people. Yeah, I wanted to say just one thing. I'm sorry for my Sobrek friends because I don't speak Brazilian, but I speak Portuguese, but I speak a little bit of Spanish. If you have a question in Spanish, I can understand it and probably give an answer. Thank you for your presence here. If you want, I can translate from Portuguese to Spanish. Yes, probably. Okay, Néstor, thank you. Well, now we'll start. Luis Aguinaga, he's the president of the Argentine Federation of Cardiology. After him, Dr. Jorge Marim, in representation of the EP Society of Colombia. Dr. Luis Quiñanir from Chile. From Brazil, Cristiano Pisani, the scientific director of SOBREK, the Brazilian Society of Arrhythmias. Our last representative, Daniel Manina from Uruguay. Another large representative from the Dominican Republic, Fernando Vidal. And from Peru, Richard Soto Becerra. I think it's a moment to start with the video. Thanks. I am Dr. Luis Aguinaga, and on behalf of the Argentine Federation of Cardiology, I would like to thank the Organization Committee of the Arrhythmias Society for inviting us to present our main clinical problems in our country. We choose as a clinical problem, age-related deprivation in Argentina. And I would like to present data about our national program, Argentina Without Ather Fibrillation. The main objectives of our registry was, or were, fight against ather fibrillation. Assistance, focus on detecting new cases, and proper management of sub-treated patients with ather fibrillation. Educational, patient, physician, and community education. And finally, investigation to obtain our own data and sub-studies. We address our problem to the community and the physicians. And also, we include useful information for patients. Information about ather fibrillation and some maneuvers as know your pores and some treatments as anticoagulation or catheter ablation. And the main resource of our registry were more than 400 of researchers took part in our registry. And all the provinces of Argentina were included. And the program started in June 22. And as you know, according to the Global Burden of Disease published in 2014, the prevalence of ather fibrillation in Argentina was zero or five percent. And in our registry, the results were we included more than 9,000 of patients. More than 1,400 patients didn't have diagnosis of ather fibrillation previous to the registry. And more than 8,000 have sub-treated ather fibrillation, mainly due to anticoagulation. And the main risk factors were hypertension, diabetes, hypercholesterolemia, smokers, obesity, heart failure, and pulmonary disease. And regarding to anticoagulation, almost 30 percent of patients, high-risk patients, were off anticoagulation. And 50 percent of low-risk patients were on anticoagulation, on the contrary. And 30 percent of high-risk patients were on antithrombotics. And finally, the main socioeconomic problems detected were poor patient education, limited access to health systems, unequal access to medicines, mainly anticoagulation, and unequal access to catheter ablation therapy. We think that the first step to solving a problem is to recognize its existence. But we know that in Argentina, we have a big problem regarding to ather fibrillation specifically. And also, we need to lead different actions to solve this main pandemic problem. Thank you for your attention. Good morning, my name is Jorge Marín, I am a cardiologist, electrophysiologist in Colombia. And we are going to talk a little about the epidemiology of heart disease in our country. I have no conflict of interest. And it should be noted that cardiovascular mortality in our country is a very important cause, the first of all. In 2021, almost 52,000 deaths were registered due to cardiovascular disease. The large percentage of these deaths are due to ischemic heart disease, followed by cerebrovascular disease, and hypertensive disease. Unfortunately, we do not have a record of heart disease in our country. It is estimated that up to 25% of all heart disease ambulatory consultations are related to arrhythmia. And there is a great increase in the incidence of these. By 2016, according to the WHO, 350,000 Colombians suffered from some type of heart arrhythmia. And among them, the most frequent is fibrillation. Which represents 50% of the arrhythmias in Colombia, with an increase in the presentation of the same, with a prevalence that for 2003 was 41% and for 2017 was 87%. With a great economic burden, being in asymptomatic patients with an annual consumption of $2,500 more or less, and in patients with complications with cerebrovascular disease due to fibrillation, up to $24,000 for the annual attention of these patients. The other major pathology that has a great incidence in our population is cardiovascular attack, within which it should be noted the ischemic heart attack, since daily in our country, for the year 2019, 100 patients had a neocardial heart attack and up to 20% of them had ventricular heart attack, which can become chronic and require intervention from us. And the other cause, which is common in Latin America, is chagas disease, which in our country has a prevalence of 1.6%, equivalent to almost a million patients in our country, and you can see the distribution in the Colombian East of the disease. We also have supraventricular tachycardia, which corresponds approximately to 2% of the patients who consult for cardiology, excluding the auricular fibrillation and the auricular ploter. Also, bradycardia occupies a similar percentage of 2%, although we do not have an exact knowledge of the incidence because we do not have a record of this infection. The strategies involved in the management of these diseases in our country obviously involve the integral management by cardiology of the care of patients with arrhythmias, and in the year 2022, more or less, 8,000 ablation procedures were carried out with curative pills of the arrhythmias in our patients, and of these, 3,600 procedures correspond to three-dimensional technology. And the distribution by pathologies is 36% of the ablations are auricular fibrillation, 14% ventricular tachycardia, 45% non-complex supraventricular tachycardia, and 5% auricular tachycardia. With respect to the management of bradycardia and the implantation of devices, according to the industry that helps us in our country, almost 4,000 devices were implanted, and you can see the distribution as the most common, the palpation and chambers, followed by the cardiodesfibrillators, both for primary and secondary prevention of the disease. What challenges do we have at this time in the electrophysiology of our country? We need to increase the use of databases and strengthen these collaborative databases to improve our knowledge of the epidemiology of the disease, to educate the population and the medical professionals, and at this time in the country we are carrying out the discussion of a health recovery that we hope will continue to benefit the population, which has kidneys in our country. Thank you very much for your attention. Hello, my name is Luis Quinanier. I'm a cardiac electrophysiologist from Temuco, Chile, and in the next five minutes I'm going to try to give you the landscape of electrophysiology in our country. As you probably know, we are this tall, long country. We are about 19 million people living here, and almost 80 percent use the public system in Chile, which is called FONASA. FONASA has full reimbursement for pacing and ablation, so that means the patient doesn't have to pay anything to get a procedure done. But the problem is, as many countries in Latin America, there is a really long waiting list. So a patient has to wait almost three or five years even to get an ablation in some areas in the country, and PBI is not an option for many patients in the public health system. Different is for pacing, because for pacemaker, the government has special programs, so you have to wait less to get a pacemaker in Chile. In the other hand, you have the private sector, which is called ISAPRES. ISAPRES has obviously more availability, so there is almost no waiting list, but the problem is reimbursement. These private companies don't give you almost any reimbursement for catheter, equipment, mapping, and eyes, so that means the patient has to pay the full price. And also, it means that sometimes you, as an EP, use less equipment, or less catheters, for example, less HD mapping, like pentarray or HD grid, because it's really expensive and patient has to pay almost the full price. Five percent use other health systems, for example, police and military. And the workforce, we are around 900 cardiologists in Chile. In Chile, to become a cardiologist, you have to do three years of internal medicine and two years of cardiology. We are about 35 electrophysiologists in the country. This is a specialty that is not recognized by the government, so the training is diverse among people. Some people do one-year or two-year fellowship, but most people have a two-year fellowship that can be done in Chile or overseas. We have four institutions that have an EP fellowship here in Chile, Santiago, Concepcion, and Temuco, where I work. But having said that, most people do a fellowship overseas to get really an exposure to complex EP. The public system, we have these numbers. This is the production from last year in all 2022 along the whole country. And as you can see, the most common procedure was pacemaker. We have more than 5,000 pacemakers being done in the public system. Around 300 defibrillators and TRTs each. And ablations, there were done almost 700 ablations. But these 700 ablations were concentrated only in three EP centers in Chile, one in Santiago, one in Concepcion, and one in Temuco, where I work. These three hospitals have dedicated EP labs that we only do EP, and we don't have to specialties like interventionals or vascular. In the private, we don't have strong data, so we don't know how many procedures are done in Chile, but there is some clinics and private hospitals that do plenty of ablation, especially in Santiago, the capital. We do have numbers from the private companies like Johnson & Johnson and Abbott and Medtronic. And so mapping system, we have Carto and Nsight in Chile. Nsight is quite new. Last year, 2022, were done only six cases with Nsight. Carto is the most common, so there are the numbers there. 460 cases were done. And from these numbers, 270 AF ablations using RF with Carto. This is public and private. And Medtronic is a number provided by them. We did 70 cases of cryo-PBI. So last year, in the whole country, we did 330 AF ablations in Chile in 2022. In scientific societies, we try to be as active as possible. We have, obviously, the Chilean Cardiology Society. We are 900 affiliated cardiologists and other professionals that are dedicated to cardiology like nursing or physical therapy. We have a small arrhythmia department with 50 affiliated. 35 of them do interventional EP, but we have also really amazing clinicians that do pacemaker follow-ups or genetics or other arrhythmia related to EP. And we try to be as active as possible. So we do monthly Zoom meetings to try to discuss clinical cases or maybe review an interesting journal. And we do an annual meeting that are done in different cities in Chile. This is a beautiful picture. You can see here from the meeting last year in Puerto Vallarta, 2022. As you see in the picture, we are already really happy after a full day of discussing EP clinical cases. This is Karina Hardy here in the middle from Brazil. And the last minute in this talk, we'll be talking about the gaps. So in the public, we need to do more EP. We need more electrophysiologists in Chile. We need more EP labs, because most colleagues are really busy doing pacemaker, and they don't have time to do an ablation. And in the private sector, we need to improve reimbursement. So these private companies doesn't give you almost any reimbursement from catheters. So we need to improve that to be able to use a catheter, HD mapping, and ICE. Thank you so much. I'm really looking forward to discussing this with you. Hello, everyone. My name is Cristiano Pizani. I'm the scientific director of SOBRAC, Brazilian Society of Arrhythmias. And I'm going to bring you here on the Latin America Summit 2023, the clinical issues in Brazil. I'd like to thank Lars and Harvard Society for the invitation. This is our data of our group, but it reflects most of Brazil. Most of the ablation procedures is SVT ablation. The reason is because this is a public system patient. In the private, we had 50% of the ablations are atrial fibrillation ablations, and 50% are non-atrial fibrillation ablations. But one important point that I want to bring here is we have a lot of patients with scar-related VT. Almost 20% of our procedures, 15% to 20% of our procedures are scar-related VT. And most of the procedures, 57% of our procedure of scar-related VT procedures are child disease. So child disease is still a big, important issue, clinical issue in Brazil. And why does this occur? Child disease is an infectious disease. And we expected during the years that the number of patients with Chagas has decreased. But what we can see here that we have this reduction, compared in 1990 to 2019. But still, there are some states in Brazil, especially in the Midwest and Northeast of Brazil, the number of deaths related to Chagas is very high, especially Goiás, Bahia, and Minas Gerais. So Chagas, especially on those states, and our center that is in Sao Paulo area for low risk of Chagas, but we have many referred patients with Chagas. This is a big problem for us. And what's the pathophysiology of Chagas? Do we have the bug that infects, and this is a chronic disease, and we have fibrosis induced by the bug, but also we have autonomic denervation, and we have some ischemic abnormalities that creates a scar, especially in the infralateral basal area, and especially on the apicardial surface. What we do to treat Chagas? ICD for patients with secondary deprivation and primary deprivation is still not clear in Chagas disease because those patients die suddenly, but many patients die due to heart failure. And this is a progressive disease. This is a chronic infection and progressive disease. So this is a meta-analysis from Andre do Carmo from Minas Gerais when he was in Canada, showing that it's not clear the benefit of the ICD in patients with Chagas. And we have the Chageski study that is in development. Actually, they stopped inclusion of patients. They are on analysis of data. And so we have the clear role of the ICD in Chagas disease, especially for primary prevention. But also a big issue in Chagas disease is the ventricular tachycardia. Ventricular tachycardia is very common in patients with Chagas. And most of the ventricular tachycardia are related to the infralateral basal adrenals. Chagas have a apical and infralateral basal adrenals. And most of the Chagas disease, they have apicardial VT. That's why apicardial ablation was developed in our center by Dr. Mauricio Scannavaca, Dr. Eduardo Sousa, because they had many patients with Chagas and with failed endocardial ablation. So they had the idea using the anesthesiology needle to reach the apicardial. And many patients could be adequately treated using this approach. But what we can see here, there are many patients, it is a proof of this that we can see, this is my thesis. We have many patients with no endocardial scar and they have a very large apicardial scar. So apicardial ablation is necessary in patients with Chagas. Our current workflow in the in-court is if the patient has Chagas disease, we go directly to the apicardial. And if you get VT non-induced and eliminate of the substrate, sometimes it's not necessary to go to end. If the patient still has some VT or there are some areas related to coronary arteries and phrenic nerve or mitral isthmus VT, then we go endo. But usually in all patients with Chagas, we go api and if necessary, go endo. This is Cristiano Dietrich recently published data showing that there's a series of 70 patients with Chagas. If you could eliminate all the late potentials, it was a late potentials in silence technique. The follow-up was good. But patients who still have late potentials, who still have substrate, they have a very high recurrence rate of ventricular tachycardia. So some other things we must use for treating Chagas. And we are very happy and we felt that this could be one solution is the radiotherapy. Radiotherapy, we can have a transmural lesion. We have now eight patients included. This is the first patient we just published this data. And what we can see that the patients can have VT on the first months, but after this blanking period, that could be four months, most of the patients get no more VT. So this could be promising. One issue, one limitation of the radiotherapy could be the stomach and the bowel. But in this series, we have no problem with this. So this could be promising. To conclude, despite improvements in public health, Chagas disease and Chagas disease VT is still a major problem in Brazil, especially in some states in the Midwest and Northeast. Stratification with cardiac MRI is important, but the role of ICD is not completely known and Chagas study will bring us some more data. Typically, cardioblast is necessary in most of the patients, or I'd say in all patients. And radiotherapy can be a solution, it can be a good option for those patients. Thank you for your attention. And now later we will have a very nice discussion. Thank you. Good afternoon, I am Daniel Banina and I am going to talk about some epidemiological data of arrhythmias in Uruguay. This story begins in February 1960, when Dr. Orestes Fiandra places one of the first prototypes of the PASO brand designed and made by Rum Elqvist at the Karolinska Institute in Sweden. Already in those early days, in the 60s, 70s, Dr. Fiandra realizes that the main limitation for the patients to access and benefit from this technology is the economic one. Therefore, he comes up with something innovative, which is the National Resource Fund. It is a non-state public body that is financed with the contribution, a small contribution of all the workers in the country, plus government contributions. And in this way, it covers 100% of the inhabitants of the country of any high-cost technology, regardless of their economic situation. This has allowed the development of electrophysiology. The first thing that was developed, in addition to other cardiological techniques, were the PASO brands. There are 14 implants, 14 implant centers in the country. And there are new centers, 9 centers that make cardiopulmonary implants and speeches. As for the PASO brands specifically, these are the statistics of the fund from 2004 to 2022, where it is clearly seen that there is an increase accompanying the global trends, the decline of the pandemic and how we recover the pre-pandemic levels. Specifically, in blue we have the PASO brands requested by the doctors, in green the authorized ones and in red the ones denied by the fund, which are less than 1%. This is a correct situation. This is how the whole system should work, where basically a person who is seen by a doctor and needs a PASO brand is given the PASO brand without problems. If we make the comparison with implants per million inhabitants and compare with other countries, we choose the European Union because we have many similarities that we will discuss later. But basically Uruguay has 400 implants per million inhabitants, when we should have a much closer figure to the European one of 1,000 implants per million inhabitants. Why did we choose Europe? Well, the evolution of the population pyramid in Uruguay has made us have in the 1960s a young pyramid with a very broad base of young people, an old pyramid, an inverted pyramid, a decrease in birth rate and emigration that make Uruguay have a population. Here you see the Uruguayan pyramid compared to the European one, they are very similar. So the limitations of Uruguay is that we do not have enough PASO brands there is no discrimination in the data provided by the National Resource Fund, neither in the diagnosis nor in the type of device. And we have technological limitations that there have been great technological advances in recent years, but the National Resource Fund has not incorporated the PASO brands without cables, it has not incorporated the remote monitoring that is only available in a center, it has not incorporated all resynchronization materials, we are limited, for example, we do not have access to cell wallets and we have limited indications of the stimulation of the left branch. As for the defibrillators, the situation is much darker, implants have been increasing over time, in blue we have the implants requested by the doctors, in green the authorized, in red the denied, the Fund denies 43% of the applications. Why does it deny it? Because the Fund has its own regulations that do not require international and globally accepted scientific evidence. For example, in primary prevention in chemical cardiopathy, the Fund requires that patients have a fever of less than 35, but greater than 20. All patients with a fever of less than 20 are excluded. And they also have to have one or two of these risk factors. If they do not have any of these risk factors, they are also excluded, and if they have three or four, they are also excluded. If they have class 1, class 3 or class 4, they are excluded. In non-chemical cardiopathy, the situation is worse because it does not cover any type of indication. Never in its entire history has the Fund covered any implant in non-chemical cardiopathy. And if we compare the implants per million inhabitants, we see that Uruguay has 60 implants per million inhabitants, compared to Europe, which has 174. We should be much closer to those figures in Uruguay. As for studies and talks, the history of studies and talks begins in the 1980s, when Dr. Palmira Bansini, who was the mother of electrophysiology in Uruguay, began her first studies in 1981, after graduating abroad in San Pablo. Dr. Simon Milstein, in 1983, goes to Canada and graduates with George Klein, and then settles in Minnesota, and many electrophysiologists went to graduate there and returned to designate them. She is the mother and father of invasive electrophysiology in Uruguay. Unfortunately, in Uruguay we also have regulatory and important problems in this aspect. In 2008, the government established an Integral Health Assistance Plan, and there it is established that it is what providers should give to patients, but studies and talks were intentionally excluded. The excuse is always the economic one, which is very expensive, but it should be remembered that the Fund spent 4.5 million dollars on the available data, and 2.3 million dollars on carefillers. And in other techniques that it has been incorporating recently, ranging from oncological drugs, assisted reproduction, mechanical treatment of strokes, TAVI, or all endoprothesis and peripheral interventions, only in oncological drugs it spent 35 million dollars in a year. Despite these regulatory limitations, which have not allowed the development of studies and talks, there are four teams working in new hospitals. Conventional talks are made about 500 per year. The most common diagnoses are anodal re-entry, accessory bias and flutter, with successes of 98, 99, 95 percent, similar to Europe and the United States, which speaks of a highly trained medical population. And with the three-dimensional mapping system, very few cases are made. We have an estimated success of 45 percent in the first procedure, with the recurrence of auricular fibrillation of 25 percent every six months. The big problem in Uruguay is that, apart from the regulatory, there are very heavy tax systems, which means that supplies count almost four or five times what they cost in the United States. And it also determines that the equipment is old. We still have some first-generation trials running, we have second-generation trials, we don't have the most modern systems, we don't have high-density mapping catheters, we don't have contact force, we practically don't have CRIO, which just arrived in March, but no patient has been made, and we practically don't have ECHO, which, although there is, the cost is prohibitive to use it in all patients. So, in a FODA analysis, Uruguay has as strengths a system of universal coverage that is highly trained, with comparable results to developed countries. In terms of weaknesses, we have a very hard tax system, very heavy, which limits access to technology, and that we have old technology. The opportunities are that the expansion of electrophysiology in neighboring countries will help us, and is promoting the development of electrophysiology in Uruguay, and our great threat are the bad sanitary regulations that we have. And since in the end everything ends well, if it doesn't end well, it's not the end. We are convinced that the best for electrophysiology in Uruguay is yet to come, and we thank you very much for listening to us. See you later. Hello. It's a big honor for me to be here, to share with you our Dominican Republic clinical experience in the arrhythmia field. I will continue my presentation in Spanish. As I said, I represent the Dominican Republic, and we will talk a little about demography, risk factors, statistics, and our main challenges. The Dominican Republic is a country of 48,670 square kilometers, with an approximate population of 11 million people, divided equally between women and men, with an overall life expectancy of 74 years, a little older for women, about 77, and for men almost 72 years. The biggest cause of death is cardiovascular disease, representing 70% of deaths in 2022, according to the National Office of Statistics of the UN. As for our risk factors, according to the study published in LACC 2018, the Dominican population has 31% arterial hypertension, with slight predominance in women, obesity 60%, sedentarism also 60%, diabetes mellitus 5.6%, premature cardiovascular disease 33%, and tobacco use only 12%. As for auricular fibrillation, which is our main problem of arrhythmias, the Dominican Institute of Cardiology, in a sample of a little more than 300 patients accompanied for a year, who had devices, found in electrocardiograms, at least three per year, an incidence of 6.2%, and it is estimated that the overall incidence of the population above 65 years of auricular fibrillation is between 8 and 9%, representing this approximately 50,000 patients. Stroke is a very important problem in our region, and in our country in particular with a figure that exceeds 170 annual cases and represents in this way the main cause of death in the entire region of Latin America and our country as well. Even so, social security does not cover direct anticoagulants for patients, it has a coverage of approximately 200 dollars per year in medicines, and a direct anticoagulant for a month costs 120 dollars. In relation to the statistics or informal data that we have made according to a questionnaire, our main arrhythmia problem is auricular fibrillation, bradycardia and blockages are very common as well. Although ventricular tachycardia or ventricular arrhythmias in ischemic cardiopathy is very frequent, there is very little reference, therefore very few speeches, even when ischemic cardiopathy is the main clinical problem in our country. This represents a high incidence of sudden death and also of ischemic cardiopathy failure, being this more than 50% in the data presented in Circulation in 2020. The second cardiopathy etiology is valvular, then followed by congenital pathologies. We have 15 electrophysiologists specialists, divided into 12 electrophysiology laboratories. Four of these laboratories have three-dimensional masps approved by FDA. A cryovabilation system that presents many problems with the importation of nitrous oxide, which makes productivity difficult. Approximately 1,500 devices are implanted in the country, these being very few defibrillators, very few high power. Approximately 600 speeches are made, of which 150-200 are auricular fibrillations. To graph what happened after the beginning of social security, we have this design, which is the statistics of the Dominican Institute of Cardiology. Since 2007, when social security coverage began, devices were fired, but even today, there is no coverage for high power devices. What are our main challenges in the future? Above all, promote communication at all levels, between specialists, institutions, public administration, generate our own statistics, educate not only the population, but also our colleagues, internal cardiologists, general doctors. After this, and this communication, generate policies, not only of prevention, in terms of generating greater device coverage, but also of medicines. Thank you very much. It is a pleasure to be able to address all of you and to be at the Summit HRS L'Arche 2023. My name is Richard Soto de Serra. I am an electro-physiologist at the National Institute of Cardiovascular Sciences, INCOR. Today we will talk about the current state of heart rhythm disorders in Brazil. We do not have national records that describe the epidemiology of heart arrhythmias. However, our experience in conventional speech began in 1998 with the author Ricardo Segarra, who was the first electro-physiologist in Peru to carry out this type of procedure. And from 2017, our experience in 3D speech began at INCOR with the CARTO3 technology, which allowed us to develop a very interesting experience and case study, which has allowed us to develop records and studies that evaluate the effectiveness, safety and impact of 3D speech on the quality of life of patients. We do not have epidemiological records, but we do have data that registers the entry of catheters and devices in 2022 in our country. Regarding heart stimulation devices, bicameral heartbeats are the most frequent, a total of 1,782, followed by unicameral in a total of 907. Heartbeat prevention devices, such as unicameral defibrillators, reached a total of 92, followed by bicameral in a total of 122. The number of heartbeats implanted per million inhabitants in Peru reached 84. If we compare it with Europe, the number of heartbeats implanted per million inhabitants is 938, a fairly significant difference between both populations. Regarding speech catheters, conventional catheters were the most frequent, 587, and also the 3D speech catheters, 292. This is interesting because it has been increasing progressively. At the National Institute of Cardiovascular Sciences at INCOR, we have data that allows us to identify the diagnoses that led to miscarriage implants. In 2022, we identified that blockade B was the most frequent diagnosis that led to miscarriage implants, 70%, followed by sickle cell syndrome, 30%. Regarding the DICE implant, the diagnosis or reason was primary prevention, the most frequent, 80%, followed by secondary prevention, 20%. The most frequent diagnosis was hypertrophic myocardiopathy, 52%, followed by ischemic cardiopathy, 17%, and the other cardiovascular diseases. Regarding conventional speech, the most frequent diagnosis was tachycardia by input B, 84%, followed by intranodal tachycardia, 16%. Regarding 3D speech, in 2022, ear fibrillation was the most frequent diagnosis, reaching 34%. And we have the first 3D speech record in Peru, which was published in 2021. We included 126 patients, and the most frequent diagnosis was ear fibrillation at 19%, followed by ear tachycardia and ear stress. The acute success reached was 95.9%, and the free survival of recurrences was 74% per year. Complications reached 4.8%, and we had no more. A study has also been published that evaluates the impact of 3D speech on quality of life in patients with idiopathic ventricular arrhythmias at the National Institute of Cardiovascular Research. For this, we carried out an analytical study that compared the quality of life in these two groups of patients, 3D and antiarrhythmic speech. We used the SF36 questionnaire, and the total score achieved in the 3D group was 85.1, versus 68.4% in the antiarrhythmic group. There was a significant P. We concluded that there is a low coverage of attention to patients with cardiac arrhythmias, and this is because we have a reduced number of electrophysiologists, a reduced number of specialized centers in the management of cardiac arrhythmias, and poor funding in some groups of patients. It has been shown that there is a very low number of devices implanted per million inhabitants in our country, and our records show that 3D speech is an effective and safe method for the treatment of complex arrhythmias in Peru. The new technologies have undoubtedly helped to improve the effectiveness and safety of this procedure, and in turn, it has been shown that there is an improvement in the quality of life of patients who go to 3D speech, especially those who have arrhythmias. Thank you very much for your attention, and we will see you again very soon. Thank you very much. Thank you very much. I would like to introduce the following speakers. From Ecuador, we will start with Jorge Arbaiza. He will represent the Ecuadorian Society of Cardiology. After him, Federico Malavasi is our large representative from Costa Rica. From Bolivia will be Roberto Torres Molina. That is also a large representative. After him will be Dr. Shamya Venchetrit from Venezuela, in representation of the Arrhythmia Committee of the Venezuelan Society of Cardiology. From Salvador will be Marta Reyes. That is our large representative. And finally, from Cuba, Elibet Chavez. Please start with the presentations. Thank you very much. en estas jornadas de Latin American Summit del 2023. Les habla el doctor Jorge Luis Arbaiza Simón. Soy médico cardiólogo y electrofisiólogo de la ciudad de Quito, Ecuador. Vamos a hablar sobre los datos de electrofisiología en nuestro país. En primer lugar, estamos hablando de un país en el cual la expectativa de vida en los últimos 50 años ha elevado de una manera importante. Estamos hablando que tenemos en este momento una expectativa de vida de 73.7 años y eso implica que a más población envejecida nos enfrentemos a más arritmias, fundamentalmente lo que es la fibrilación auricular. Esto es un pequeño resumen de cómo está organizado el sistema de salud en el Ecuador. El sistema de salud en el Ecuador, como vemos, tenemos un total de establecimientos de salud de 630, de los cuales existen más del servicio privado que del servicio público y tenemos un total de atenciones, en este caso de egresos hospitalarios, de alrededor de un millón de pacientes por año. Como podemos ver, a pesar de que hay más empresas privadas que públicas, el número de egresos de camas públicas es mayor. Cuando queríamos ver con respecto a la incidencia y a la prevalencia de las enfermedades del ritmo cardíaco, nos estamos enfrentando a esta situación. Analizamos las 10 primeras causas de muerte, como podemos ver en esta gráfica, y si bien es cierto, tanto en nuestro país como en otros, el COVID ha representado la principal causa de muerte en el año 2020-2021. Las enfermedades del corazón están en segunda causa, pero específicamente la enfermedad isquémica. Y si vamos a buscar como causas de mortalidad de arritmias cardíacas, no las encontramos entre las primeras 10 causas de muerte. Entonces, específicamente, ¿qué podemos decir del Ecuador? Una estadística nacional de incidencia y de prevalencia de enfermedades del ritmo cardíaco no existe, lastimosamente. Se está tratando de hacer, a través de la Sociedad Ecuatoriana de Cardiología, un registro, específicamente en la ciudad de Quito lo estamos haciendo, con ocho hospitales, tanto públicos como privados, los más grandes de la ciudad. Y les puedo poner específicamente del hospital en el cual yo trabajo, en el cual, por ejemplo, en el año 2022, tenemos 235 casos de fibrilación auricular, que representaría el 3.2% de todos los diagnósticos realizados en pacientes hospitalizados. Esto, por supuesto, no es un número que esté representando prevalencia ni incidencia de la enfermedad, pero podemos tener una cierta aproximación en cuanto a este número. ¿Cuáles son los requisitos en nuestro país para poder ejercer como electrofisiólogo? Tener título reconocido de cardiólogo con subespecialidad en electrofisiología. Existe una entidad nacional, conocida como Cenecida, actualmente conocida como Axis porque cambiaron el nombre, el cual se encarga de reconocer estos títulos. ¿Qué cantidad tenemos en el país? Tenemos 33 electrofisiólogos, en las ciudades principales, más que todo en Quito, Guayaquil. Contamos con Cuenca, Manta y Loja. Son las cinco ciudades en las cuales tenemos especialistas de la subespecialidad. Lastimosamente, no existe un fellow here en el país. Todos los electrofisiólogos del país son formados en otros países. Y podemos sacar una estadística. Si en el país hay 17.8 millones de habitantes, podemos decir que hay un electrofisiólogo por cada 540 mil habitantes. Con respecto a alguna asociación gremial, desde el año 2020, precisamente con motivo de la pandemia, empezamos a tener reuniones dentro de la Sociedad de Cardiología para tratar de organizar lo que son los comités. Específicamente, se organizó el Comité de Electrofisiología con la cuestión interesante de que contó con los especialistas de todas las ciudades que habíamos mencionado. Desde entonces, hemos podido organizar varios eventos nacionales y tres jornadas internacionales, tanto con el aval de la CIAC como de la Sociedad Latinoamericana del Río. No existe ninguna relación con entidades gubernamentales y en ese sentido no tenemos el apoyo del gobierno. En cuanto a centros y tecnología disponible, contamos con 15 centros en las ciudades ya mencionadas. Se utilizan sistemas de mapeo convencional y tridimensional desde hace algunos años ya el tridimensional. Se utiliza tanto la energía de radiofrecuencia como la crioblación. Como cuestiones novedosas, se hacen en algunos centros cardioneuroablación. Se utiliza el eco intracardíaco como un método para colaborar en la mejoría de los procedimientos. Y en cuanto a dispositivos, podemos decir que se implanta todo tipo de dispositivos. Marcapasos con estimulación convencional, con estimulación fisiológica, cardiodesfibriladores, resincronizadores, grabadores de eventos. Es decir, podemos decir que en el país se hace todo tipo de procedimientos. Con respecto a la cobertura médica, pues lastimosamente en la parte pública solamente existen dos hospitales a nivel del estado y tres hospitales a nivel de lo que es la seguridad social para practicar lo que es la electrofisiología, pero lastimosamente, sobre todo en los últimos años, tenemos mucho problema en lo que es los materiales. Hay mucha falta de material. En cuanto a clínicas privadas haciendo convenio con seguridad social o estatal, en la actualidad lastimosamente es casi nula, sobre todo por falta de pagos. Y respecto a las clínicas privadas, existen muchos seguros privados, pero lastimosamente muchos de ellos no dan lo que es cobertura de materiales, y sabemos que los materiales es lo más importante en los gastos de un procedimiento de electrofisiología. Y también en el Ecuador, contamos todavía con muchos pacientes que se considerarían como autofinanciados en clínicas privadas. Lastimosamente, y por eso lo subrayo en letras grandes, el alto costo de materiales respecto a países de la región, y lastimosamente es más que todo por falta de representantes directos de las compañías, nos ha traído que los costos sean muy elevados en los procedimientos, sobre todo en los mapeos tridimensionales, y los altos impuestos que hay para la importación de equipos también nos traen grandes dificultades. Respecto a la tecnología, pues contamos con las grandes empresas, con ABOT, más de 20 años en el país, a través de la nacional llamada CGMED, con ellos podemos contar con todos los sistemas que estamos mencionando aquí, también Metronic, aproximadamente 20 años, a través de Ecuador Overseas, tenemos la empresa Boston, a través de una empresa nacional llamada Equasurgical, y el último que ha entrado es BioSense Western, es decir, Johnson & Johnson, a través de una empresa nacional llamada Primus Medical, que ha traído el sistema CARTO. Existen pequeñas representaciones regionales de lo que es Biotronic y médico SPA. Si hablamos de políticas de salud nacional, de parte del Estado, pues como dijimos en un principio, no existe un plan específico por parte del Ministerio de Salud Pública del Ecuador, respecto al manejo específico y general de las arribas, y se está planificando a través del Comité de Electrofisiología la conformación, quizás en un futuro no muy lejano, de la Sociedad Ecuatoriana de Electrofisiología, como una entidad independiente. Por último, queremos mencionar algunas estadísticas aisladas de centros de alto volumen. En este caso, gracias a la ayuda del doctor José Llorente, podemos contar con las estadísticas de dos clínicas grandes de Guayaquil, en este caso la clínica Alcibar, que podemos ver un total entre el año 2020 y 2023 de 786 pacientes. Como vemos, mayor carga de pacientes en lo que es ablación convencional de taquicardias paroxísticas. En segundo lugar, la fibrilación auricular y arritmias auriculares en general. Después, el uso de marca paso para arritmias, la ablación de arritmias ventriculares, y por último, cierre de orejuelas. Otro hospital de Guayaquil, 480 pacientes del año 2018-2023. Igual predominan las taquicardias paroxísticas. Y respecto a un centro de Quito, en el cual yo laboro, el Hospital Bosán de Quito, del año 2020-2023, 499 pacientes, de los cuales igual, predominan los pacientes de ablación convencional, taquicardias paroxísticas. En segundo lugar, fibrilación y flúter. En tercer lugar, arritmias ventriculares, todo es trasistolea ventricular. Y tenemos también lo que es la estimulación, tanto de marca paso normal como uso de cardiodesfibriladores o resincronizadores. Esto es todo lo que teníamos con respecto al Ecuador. Agradecemos nuevamente la oportunidad de poder participar en este evento de la Sociedad Mundial del Ritmo, y queremos pues despedirnos de parte de este país tan megadiverso como es el Ecuador, con sus cuatro regiones. Muchísimas gracias. Cordial saludo. Soy Federico Malabasi, cardiólogo-electrofisiólogo de Costa Rica. Voy a presentar los datos sobre el estado de electrofisiología en nuestro país. Vamos a comenzar con la incidencia de la arritmia más frecuente en nuestro país, que es la fibrilación atrial. La población de Costa Rica es de 5.2 millones, según el dato del Censo Nacional realizado en el 2022. La incidencia de fibrilación atrial es variable según los grupos de edad. Antes de los 55 años, los casos son aislados. Ni siquiera llega a un reporte de uno por cada mil habitantes. De 55 a 64 años, la incidencia es de cinco de cada mil pacientes, de 64 a 84, la incidencia se duplica a 10 de cada mil, y más de 85 años o más, ya tenemos una incidencia de 35 casos por cada mil habitantes. En cuanto a la segunda patología más frecuente, de lo que es respecto a la electrofisiología, tenemos arritmias supraventriculares. Ahí se incluyen reentradas, se incluyen flúteres. Tenemos una incidencia en dos grupos de edad reportados según el Censo, que es de 20 a 55 años, y arriba de los 55, ocho de cada mil habitantes. En el 2022, tenemos un registro de 30 episodios en Estadística Nacional de Pacientes con Fibrilación Ventricular y 100 episodios de tarquea cardioventricular. Es importante tener claro que puede y evidentemente hay un subregistro en cuanto a lo que son arritmias ventriculares, porque muchos pacientes han presentado como primera presentación muerte súbita y no se está clasificando como tal dentro de arritmias ventriculares. Posteriormente, tenemos un diagnóstico de atención por bradicardia. Son mil casos al año en la estadística del Censo Nacional. Si vemos la producción de procedimientos de electrofisiología como segundo apartado, tenemos un reporte de 150 ablaciones a nivel nacional de fibrilación atrial, 300 casos de ablación de arritmias supraventriculares, 50 casos de ablación de arritmias ventriculares. Esto incluye tanto ablación de arritmia ventricular como tal, como ablación de extrasistolia ventricular. Tenemos implante de 800 dispositivos de tipo marcapasso, ya sea unido o bicameral, a nivel nacional. Tenemos 60 implantes de cardiodefibriladores unibicamerales y, perdón, subcutáneos también. Y, finalmente, un total nacional de 100 implantes de cardioresincronizadores. Como segundo tópico de esta presentación, voy a aclarar un poco sobre políticas de atención médica a nivel nacional. El país cuenta con nueve cardiólogos electrofisiólogos. De estos, uno es cardiólogo electrofisiólogo pediático y es el único a nivel nacional. Tenemos ocho cardiólogos electrofisiólogos, de los cuales cinco trabajan a nivel de seguridad social, tres no ejercen como tal como electrofisiología, uno solo trabaja en medicina privada. Del grupo anterior es además importante aclarar que únicamente cuatro de ellos realizan intervención tridimensional y procedimientos de ablación como tales, los otros se dedican más a la parte de diagnóstica e implantología de dispositivos. Los requisitos para el ejercicio de la electrofisiología a nivel de Costa Rica incluyen la incorporación al colegio profesional, que es el Colegio de Médicos y Cirujanos de Costa Rica. Esto tiene algunos elementos que debe completar, ya sea la electrofisiología, sobre todo en Costa Rica, requiere del estudio fuera del país. No hay programas de formación académica en electrofisiología a nivel de Costa Rica. Todos los electrofisiólogos han estudiado fuera del país. Entonces, requiere estar que cardiología esté incorporado, eso exige además tanto para incorporar cardiología, medicina interna y posteriormente electrofisiología, que se realice un año de servicio social donde lo solicite el Ministerio de Salud y además aprobar el examen de incorporación que lo realizan tres pares académicos nacionales o internacionales que nombra el colegio. Tenemos como infraestructura a nivel de seguro social, hospitales públicos, cuatro hospitales, uno para niños y tres hospitales nacionales de adultos. En dos de ellos se realiza electrofisiología, el centro de mayor volumen y el que realiza mayor complejidad en este momento es el hospital Calderón Guardia, donde se hace ablación tridimensional sin plantas dispositivos de alta y baja energía por electrofisiología. El hospital México Solo realiza implantes de dispositivos de baja energía. El hospital San Juan de Dios realiza ablación convencional, en este momento no está realizando ablación tridimensional, dispositivos de alta y baja energía y dentro de electrofisiología es el único que incluye cierres de orejuela. Los otros hospitales tienen el programa de cierre de orejuela dentro de hemodinámica y estructural, no dentro de electrofisiología. El hospital de niños sí realiza todo tipo de implantología y dispositivos de alta y baja energía. Los hospitales públicos cuentan con todo el equipamiento, AIS tridimensional, polígrafos, creolación, angiógrafos. El hospital San Juan de Dios en este momento no está realizando crío y el hospital de niños sí tiene absolutamente todos los equipos. Hospitales privados hay cuatro, los cuatro realizan todo tipo de procedimientos y tienen el equipamiento necesario. Entonces la tecnología está disponible tanto a nivel público como a nivel privado. Financiamiento de los casos a nivel de seguro social es el seguro social. Los electrofisiólogos están por salario y por tiempo, no están por caso, así que es un salario fijo independientemente de la producción que tengan. A nivel privado se paga de las siguientes maneras. El 70% del volumen viene a través de pólizas y reembolsos de gastos médicos. La mayoría son internacionales, son 30% son pólizas nacionales y pago directo del paciente, 30% del volumen. Hay financiamiento por bancos privados y casas comerciales según convenios con terceros. El reembolso en realidad 20% de los casos el paciente paga y él se encarga de su reembolso propiamente con su compañía. 80% de las veces hay que reauto reauthorize the case so that it is feasible to carry it out. The average waiting period for reimbursement, both for the doctor and the patient, is between 60 and 70 days. The origin of the patients is 60 national, 40% are foreigners. The largest volume of foreigners come from North America, that includes the United States and Canada. 8% are Europeans, 2% Central America and the Caribbean, and references. Thank you very much for your participation. Any questions, we are at your service. Thank you. Good afternoon. I am Dr. Lamberto Torres Molina, member of the Artificial Stimulation Committee, the founder of the Latin American Heart Association and the Bolivian Heart Association. It is a country that is located in the heart of South America. It has about 12 million inhabitants, according to the latest census project carried out in 2012. In recent decades, there has been an urbanization of the rural area. Currently, 62% of the population lives in the suburbs. 30 years ago, it was quite the opposite. This is the population pyramid of Bolivia, where you can see that there is almost an equality between men and women. But the most striking thing is that 50% of the Bolivian population is under 20 years old. This is the base of the population pyramid. In our country, there are different health and insurance entities. First, there is the Health University, which corresponds to the Ministry of Governance and Municipalities. Authentic health insurance companies are selected according to a well-defined population, such as the National Bank, the Petroleum Bank, Caminos, Bancario, Universidades, etc. Then there are private insurance companies, which are proprietary. Public hospitals, which treat patients at a second and third level. Health centers, which are at a first level. Private hospital clinics, and finally, health posts. According to this segmentation, for the Bolivian population, 20% are sold in these authentic health centers. 9.7% in private areas. 61% in public health establishments. 16% in private health establishments. 17% go to a traditional doctor. 40%, almost half, look for home solutions. And 46% ask the pharmacist what he can take for his patient. In Bolivia, the disease with the highest incidence is HIV. With an incidence of 8 to 12% in urban areas, and almost 30% in sub-dense areas of HIV patients. Of this disease, the main disorders are manifested. Myocardial dilatation with deterioration of the ventricular systolic function, disease of the sinus node, conduction disorders, ventricular osteophoresis, ear fibrillation, ear alopecia, and ventricular arrhythmias. This is more or less the distribution and risk management of how Chagas is distributed in Bolivia, the red dot being the one with the highest incidence, and in Delhi. There is a low incidence of other types of arrhythmias, such as supraventricular tachycardiasis, ear fibrillation, ear alopecia, ventricular oropharyngeal tachycardia, pulmonary oropharyngeal arthritis, ventricular extraceptor, and ventricular therapy. The implantation of Marcapax was initially proposed by his brother, Octavio Bastulares. It is from the year 2000 that, with pioneers such as Dr. Ronald Cuellar and Luis Rangel, the age of electrophysiology of the device implant begins. The work to which other professionals will be added, all trained abroad. It is in 2019, on the occasion of having organized the first electrophysiology and arrhythmias training, that the Arrhythmias and Electrophysiology Committee of Bolivia is constituted. In the photo, the founders. To date, there are seven electrophysiology laboratories in the private sphere, distributed in three of the main cities of Bolivia. Three authentic insurance hospitals, a single InSight browser that we have in the ocean. All other centers work with 32 or 64-channel polygraphs. There is no availability of infrascreen ultrasound. There are no training programs at the physiological level. And there is only one center that has reported the areas of auditory stimulation. Four centers. The cardiac device implant is segmented in the following way. In the private sphere, with total self-financing of the patient. In private insurances that recognize the implant and not the device. In authentic entities that some give the device and give surgery and others under revolution. And finally, public hospitals, if they have the means, perform the surgery, but do not give the device. Some statistics. In the last year, in 2022, a total of 428 procedures have been carried out. Almost half of them are physiological procedures. And they work as an intranasal implant or ventricular auditory implant. Ventricular auditory arrhythmias, 54. Four ventricular functions. Forty-six ventricular ventricles. And forty-five ventricular cavities. And the device implant, 781 devices. Of which 154 are unicameral. 606 double chambers. Twelve bipolar resynchronization therapies. One quadripolar. And eight implant cardiologists. Thank you very much. Greetings. I will comment on the current state of clinical electrophysiology in Venezuela. Unfortunately, there is no reliable data on the number of cases, both of stimulation and of invasive electrophysiology. The volume of implants in recent times has increased gradually. The recovery of electrophysiology has been slow. There has been a significant migration of... of electrophysiologists with serious training. In general, invasive electrophysiology is concentrated in some capitals of the states with a larger population. A hospital center trains electrophysiologists consecutively, and a second hospital trains cardiologists in cardiac stimulation. At the moment, they do not have any kind of university approval. In Venezuela, the health of 90% of the population depends on the state, and only 10% has private insurance with different levels of coverage. Few public centers implant devices. Some centers have a direct contribution from patients or institutions, which are known as semi-public. You can see that the third most important state in Venezuela does not have a public center for device implantation. Devices are acquired by the state, as well as by the patients themselves, by direct purchase. The largest hospital in the capital, the Hospital Universitario de Caracas, implanted more than 500 devices last year, mostly anti-radical. As for the private sector, the percentage of implants at the national level depends on the availability of state and private centers. In some states, as I mentioned in the previous slide, private activity represents 100% in general with low volume. There is no regulation that controls who implants the devices, as well as the centers suitable for such. Many private centers in the country implant. Several of them, less than 10 devices a year. The electrophysiological activity is even more complex. It is still scarce, despite a slight increase in recent years. Probably no more than two 100% state hospitals have the possibility of carrying out invasive electrophysiology. Probably less than 20 cases a year. Some semi-public centers carry out such procedures. You can see on the right slide that practically no state of the most important has the possibility of carrying out such procedures. In the state of Olara, a semi-public center carries out more than 50 implants a year with conventional technology. It is an undefined number in private institutions. The activity in private institutions, in general, tends to depend on mobile devices belonging to certain companies. In the metropolitan area of Caracas, which has more than 5 million inhabitants, more than 70 cases are carried out a year. 30 to 40% using three-dimensional navigation, in this case, the V7 card. The Chagas problem continues to be in force in Venezuela with a rebound in recent years. Six million people live at risk of contracting Chagas disease, especially in rural and semi-rural areas. There are probably more than 300,000 cases of Chagas in Venezuela. Recent estimates show that the zero prevalence of trypanosoma cruzi exceeds 10% throughout the country. Higher values in the critical transmission points are active in the states of Marinas, Lara, Portuguesa and Trujillo, which is known as the Andean Piedmont. In general, the populations are in more complex socioeconomic situations. In recent years, Chagas has been described by oral transmission, as well as cases transmitted by vectors in large urban areas, such as in the metropolitan region of Caracas. In general, few Chagas patients have high-voltage therapy. Thank you very much. Hello, I greet you, Marta Reyes, electrophysiologist from El Salvador. I thank you for the invitation to this Latin American symposium and I will talk to you about some clinical aspects in the area of electrophysiology in the country. The total population in El Salvador is 6,187,000 inhabitants. Among the clinical problems in the area of arrhythmias in the country in order of frequency, we have auricular fibrillation with a prevalence of 15% and within this, secondary lethiology is the most frequent. Other supraventricular tachycardia such as re-entry in the tranodal, accessory vias, atrial flutter, follow them frequently. Subsequently, ventricular arrhythmias related to ischemia, complete ventricular auricular blockages, most of them degenerative theology, bradycardia. Within the dysautonomy, there is 5p neurocardiogenic, which has been increased in this post-COVID stage. Ventricular arrhythmias associated with cardiomyopathies, including Chagas disease, which in our country has a prevalence of 3.3% and in a smaller percentage we have ventricular arrhythmias associated with hereditary conditions such as Coutel-Argo syndrome and Brugal syndrome. Within the treatment, we carry out speaking procedures when this is possible, either due to the ability to speak or due to the availability of the procedures, the devices when possible and in the same way. And within the treatment options available in the country, we have within the 1B group, lidocaine, phenytoin. Within the 1C group, we have propafenone. Within the beta blockers group, we have more availability, including metoprolol, arbedilol, propranolol, nebibolol and bisoprolol. Within the 3 group, myodarone in the group of calcium channels blockers, verapamilo and diltiazem, and other drugs such as atropine, divoxine and ibuprofen. Within the electrophysiological procedures carried out, we have the electrophysiological diagnostic studies, the superventricular tachycardia ablation, excluding auricular fibrillation and some ventricular arrhythmias. The device implantation, within this, is the highest percentage and in lower proportion the defibrillators and cardiac resynchronizers. What are the main problems that we face to give an adequate management or an appropriate treatment to the arrhythmias? Mainly the ability to pay for our population, the lack of technology or equipment and the facilities for the implementation of these, and in lower proportion, some drugs that we often do not have with most of them to give an adequate management. Thank you. First of all, I would like to thank the Latin American Summit of the Society of Cardiac Rhythm 2023 for the integration that is intended. I am Dr. Eliber Chavez González, Head of the Electrophysiology Session of the National Group and the Society of Cardiology of Cuba. Initially, we will present the topic that has been requested that is related to the clinical presentation of arrhythmias in our country. When an arrhythmia is documented in an electrocardiogram, patients will always be referred to a cardiologist in any of the provinces of our country for a pharmacological treatment according to the current guidelines. When they do not resolve with the pharmacological treatment, they are sent to the specialized electrophysiology centers with the aim of carrying out a treatment as a strategy of the experience of these centers that may be superior to the rest of the centers of the country. Due to epidemiology and the importance of the strategic management of arrhythmias in our country, in the case of supraventricular arrhythmias, we can say that the epidemiological behavior in terms of incidence and prevalence is similar to what is described in international literature. Here are the supraventricular arrhythmias that are presented and here are the forms of treatment that can be applied to the cardiology centers in Cuba. In the case of ventricular arrhythmias, it is worth mentioning that epidemiology is similar to what is described in literature and the treatment that is applied is related to what is described in the current guidelines for the treatment of cardiac arrhythmias. In our country, there are about 750 to 800 electrophysiological talks in the two electrophysiology centers that we have already described and that we are going to show in another presentation. From the point of view of cardiac devices, it is worth mentioning that the greatest number of steps are implanted in patients by blockage of the degenerative ventricular auricle in most of the Cuban population over the age of 65. It is very rare to find infectious diseases such as Chagas and congenital ventricular auricle blockages can appear with the need for step implantation. Devices such as defibrillators and cardioresynchronizers are also implanted. There are 15 steps implantation centers or there were 15 steps implantation centers before the pandemic in 2018 and observe that on average the centers that implant the most are the Center of the Institute of Cardiology and Cardiovascular Surgery of Havana and the Cardiocenter Ernesto Che Guevara of Santa Clara. When we are going to review the implantation of defibrillators and cardioresynchronizers observe that defibrillators are implanted approximately 178 and cardioresynchronizers are implanted approximately 190 with a rate of 10.7 devices per million inhabitants which is not similar to the European records and developed countries but we can mention that this rate is very similar to what happens in the countries of Latin America. This is the first way of implantation of cardiodefibrillators in our country. Here I show you a photo session of our capital of Havana where the Institute of Cardiology is located and Villa Clara where the Cardiocenter Ernesto Guevara is located. Thank you very much. Thank you very much so we can start the discussion now. I've been following the presentation very well and I will start the conversation with two major issues that I focus on. I say that Chaga disease is present in many countries and is probably a major problem and number two the availability of EP labs and the availability of catheters and I would say also the availability of doctors. In many countries I saw 35 to 40 EP without even proper training to get there. I would like to start a discussion saying what do you think we can do or how can HRS support number one training and number one more training of people and number two probably availability of catheters and things like that probably PFA for example is supposed to reduce the learning curve and it's probably coming late to LAHRS. Can we do something to make it sure that you get PFA soon so that the learning curve to train people can be shortened. What do you think about things like that and number three since Chagas is so important do you have protocols that can be shared from all of you, when a patient come with Chagas, we do A, B, C, and D all the time, or everybody's doing whatever they feel appropriate. So that's something that, you know, we can start with each of you comment, and then we can ask. I want to invite the panelists, Juan Carlos Serpa, and Carlos Guzman from Mexico. Yeah. And Jose Lorente, not here. That's it. Well, he says, Luis Carlos is not coming, then I invited Luis Aguinaga. Yes, Luis Aguinaga, yeah. Perfect. So, I mean, I already made a provocative question, so we'd like to hear from each of you. You know, Marcio, if you want to start, and then Nestor, and then all the panelists. Thank you, Luigi. I think that, as I saw the presentations, I noticed that there are many things in common, and there are many things that are all different. And obviously, the technology is an issue, I think that, but I really don't know how. I think that this kind of forum is important for us to figure out how can we improve technology access to our region. I think this is important. And formation, because I noticed that many countries, they don't have possibilities to form physicians. But if I may, I would like to call the attention for a step earlier, let's say, because I think that we do not have data. I think that we really should have data in our region. It called my attention that some countries, like Argentina, is trying to do so. There is some other countries that do have data on implants, but there's no, let's say, formal way of doing. I think this would be a good way, I think this would be a good way to start to make a registry of arrhythmia and centers in our region so we can have this data and we can measure the things we can do from now on. I don't know how HRS or the companies could help us on doing this. I think that the company are always important because they can help support the cost of something. But if we leave this in their hands, of course they're always gonna report the data the way they want. So I think they should be asked to support registries. I think it's important that maybe the whole LA HRS come up with registry. And like we saw in this presentation, it's been very good. How many PR for each country, how many years of training are necessary versus not necessary? And then start to build up a real workflow of things that go there. For example, we know for ablation, PFA will be a hot topic during this conference. If supposed to be the way it looks like, it should reduce the experience of the operator. I mean, of course you need to know how to get access, you need to know how to do transeptal. That part, it's RF or cryo or PFA, you need training for that, no matter what. But once you get there, for sure PFA reduce the operator experience. So I think this technology should be expedited rather than delayed. Problem is that this new energy comes at a higher cost than the prior one. And the company, I'm talking, they are not even going, want to invest in Europe because the reimbursement in Europe is not as good as US. So they are focusing on investing only in US. So I think we cannot practice medicine in a way that you have country A and country C where technology are separated. So we need to create, I think, important rules for the industry in where the technology are available. But before I give the word to you, I mean, I think we should, yes, is it possible, you think that HRS can have every country forming kind of registry? And this registry have to be, first of all, how many procedures are done? Like we saw, everybody collected data, but they have to be in a formal way. And then from there, atrial fibrillation. Then atrial fibrillation, what is the lesion set done today in paroxysmal versus persistent in the majority of the Latin American nature? Then I think there's a lot of data that come in, a lot of scientific opportunity. So I think this is a good way. Now, what we can do from US is try to support this registry and try to ask with you to the industry to support the registry and probably receive the data, have somebody from our side that collect this data and review with you. I mean, probably this is a good start. I don't know the opinion of the panel. I want to break the ice and break the idiomatic frontier of Spanish and English. Maybe if you don't have any problem, turn to Spanish to- No problem. To get more people involved. Can I do it in Spanish? Okay. I want them to participate, to speak, and to comment on their problems. Okay, perfect. Okay, Luis, you understand very well Spanish and Portuguese. Si, no problem. No problem. In Spanish? Si, yes. Okay. Completely de acuerdo. Yo creo que la primera cosa que tenemos que hacer para solucionar un problema es primero conocer la magnitude de nuestro problema. Y en chagas, y en fibrillación auricular, y en recursos, y en electrophysiología invasiva, por lo que escuchaba, tenemos más o menos similares problemas en Latinoamérica. La pregunta es muy buena, y yo estoy en el BOAR contigo, con Eduardo y demás, y siempre comentamos cómo se puede ayudar, o cómo nos puede ayudar Harlein Society a Latinoamérica. Sin duda, nuestros problemas abarcan mucho más que a la sociedad científica, ¿verdad? Abarcan los gobiernos, las sociedades científicas, los ministerios de salud, etc., etc. Pero lo que podemos hacer desde el mundo de la ciencia es muchísimo. Esto de la industria es bueno. Congregarnos acá es muy bueno, conocer nuestros problemas. Pero también acciones on-site, ¿no es cierto? En nuestro lugar, en los cursos, la formación. Es muy poca la gente que puede venir acá. En este último tiempo, y hablo por Argentina, por ejemplo, el problema inflacionario es tremendo. Este año han venido muy poco. Hoy hemos venido muy poco. Y se ha notado, y lo comentábamos con los colegas, con lo cual necesitamos acciones de educación fundamental en nuestros lugares. Recién, y les mostré hoy día, terminamos este registro de fibrillación auricular, donde se muestran grandes falencias, ¿no? Casi 10,000 pacientes en un país que ahora va a empezar para toda Latinoamérica, donde se ve el escaso acceso de los pacientes, por ejemplo, intervenciones complejas, o no tan complejas como la simple anticoagulación. Pero también se nota muchísimo la falta de educación de médicos, la falta de educación de pacientes, la falta de educación de la sociedad para mejorar esas condiciones. Yo hablando con respecto a fibrillación auricular. Chagas es exactamente lo mismo. So necesitamos un ano cero, un census. O sea, un census de todo el país con nombres totales de electrofisiólogos, el número total del entrenamiento necesario. Y mirar, para hablar con la sociedad de salud, en América tenemos 7-8% de ablación comparada a la diagnóstica de fibrillación auricular en América. ¿Cuánto es la percentual de ablación de fibrillación auricular en Latinoamérica? ¿Cuánto menos es? Menos del 1%. 1%. Es un nombre que un gobierno tiene que comprender, que no es posible que tú tienes una diferencia tan grande. Necesita dar un soporto. La sociedad americana tiene que dar un soporto también con el entrenamiento, con la educación, con una educación remota, pero la sociedad latinoamericana necesita una forma de documento global que todo el gobierno de todas las naciones van a soportar. Si no, no es posible. Sorry, let me speak in Spanish. Hablo por México. En México es una población alrededor de 130 millones de personas. El 70% de la población tiene seguridad social o algún tipo de seguridad social. 20 millones tienen seguro de gastos médicos, que no tienen prácticamente problemas por el servicio. Y ahora con los cambios, alrededor del 40, 50 millones de personas se quedaron sin acceso a la seguridad. Podemos hablar que simplemente en México hay tres Méxicos diferentes que se parecen mucho a Latinoamérica, el norte, el sur y el centro, y se concentran prácticamente todo en el centro, que son la Ciudad de México y dos ciudades extras, en Guadalajara y en Monterrey, que es donde trabajo yo. El resto de ciudades y de la población probablemente no tenga servicio de electrofisiología y los que podemos viajar hemos tenido que invertir en nuestras herramientas de trabajo. Nosotros compramos los polígrafos porque no existe en otros lugares. Aquí una de las dudas es qué pasa con el equipo, que si se puede usar equipo reprocesado, si permite usar equipo reprocesado. Creo que sería muy difícil tener un enfoque global de todo el país, que creo que sería igual que Latinoamérica. Y creo que verlo por regiones, región norte, México, región centro y región sur, sería probablemente muy diferente en cuanto a resultados, en abordajes y en tipo de arritmias que se ven. Yo puedo hablar por el norte, y en el norte fibrilación es lo que más hacemos, crónica o paroxística, y tenemos seguro de gastos médicos prácticamente el 80% de la población en Monterrey, y nuestros cobros o nuestras autorizaciones en el seguro se basan en los CPT codes, que es muy parecido a Estados Unidos, creo que en Colombia tenían otro tipo, pero que está organizado por códigos para la tabulación del procedimiento y para la autorización del procedimiento. El resto del país es muy difícil estandarizar el procedimiento y los pagos. Y la otra es que no sé si es posible o si se permite en algunas ciudades o en algunos países el reprocesado de materiales de cárcel. Gracias. Juan Carlos. Luigi, hablábamos de un problema de la ablación pulsada, que es una nueva tecnología que va a estar disponible y que promete muchas cosas, pero nosotros estamos en la realidad de pelear con el eco intracardíaco. Tratar de hacer un uso general de eco intracardíaco hasta ahora es un gran problema por el costo. Tecnologías nuevas que son poco utilizadas van a tener un costo bastante alto y van a ser poco disponibles para la población general también. Entonces, sí, tenemos un gran problema y una población muy heterogénea en toda Latinoamérica, pero reconocer los problemas que tenemos y tratar de identificarlos y abordarlos para hacer esas intervenciones que mejoren la parte de tratamiento es lo necesario. Empezar con un registro, como lo hacíamos con el registro del DECA, que se veía cuántos implantes de marcapasos se hacían, prótesis complejas, prótesis para tratamiento de choque, y se sabía la realidad que tenemos y eso hasta ahora se mantiene. Entonces, a través de LARS podríamos entonces también una iniciativa que de esa forma se reconozca cuántos son nuestros problemas, quiénes estamos dispuestos a juntarnos para poder hacer esas intervenciones y poder trabajar. Y sí, esperamos que la Pulse Field Ablation llegue pronto, pero tenemos otras cosas antes y sabemos que va a tardarse un poco más en llegar a Latinoamérica. Realmente esta iniciativa, la idea de esta iniciativa, primero es ver a través de HRS, a través de LARS, ver cuál es nuestra realidad, cuáles son nuestras diferencias. Y realmente, como lo vieron en estas primeras pláticas, es bien diferente, país a país. Entonces, estas diferencias nos han limitado en muchas situaciones. ¿Cuál sería el siguiente paso? Y creo que ahí van enfocados muchos esfuerzos de LARS. Documentar estas diferencias, tener algún registro, como decía antes, de cuántos electro-geólogos hay en cada país, de cuántos centros hay en cada país, de cuáles son las posibilidades, de cómo está involucrada la industria, qué industria tenemos, cuál es la capacidad monetaria y hacer lo que nos toca a nosotros. Cada gobierno en Latinoamérica, ustedes saben, es bien diferente. Algunos tienen más apoyo de los gobiernos que otros, pero en general es poco el apoyo de los gobiernos en Latinoamérica. Entonces, creo que lo que nos toca a nosotros hacer como médicos es registros, darle información y que esa información sea vista por mucha gente. Y relaciones con HRS, creo que para nosotros es muy importante, porque obviamente Latinoamérica, pues históricamente en todo, no nada más en medicina, siempre va un paso atrás. Entonces, esta es parte de la idea de esta iniciativa, ver qué podemos hacer viendo y estableciendo nuestras diferencias. Pero si yo vengo a pensar, yo pienso que el entrenamiento es la cosa más importante, porque cuando miro al marcapasso, el marcapasso necesita un entrenamiento un poquito menos grande. Y tú tienes muchos doctores que pueden implementar el marcapasso. La diferencia, el costo del marcapasso en Estados Unidos de América es más grande que en América Latina. Pero tú tienes disponibilidad de marcapasso. So, la industria, en mi opinión, si tú tienes más personas disponibles para hacer la procedura, yo pienso que va a reducir el costo. Si tú no tienes muchas personas disponibles, menos personas pueden hacer el procedimiento, es más difícil. So, es un problema que necesita diferentes soluciones, pero una solución es que más personas necesiten entrenamiento para hacer el procedimiento. Si no, no tiene personas para el procedimiento y el costo está siempre grande. En cuanto al training, me parece que el training lo que estamos haciendo es polarizar también a los especialistas en arritmias, porque estamos dando o se están dando proctorajes, tú eres proctor de esto, proctor de lo otro y estás limitando a realizar el oclusor de orejuela, las transeptales, el mapeo a ciertas personas. Y ahí se está polarizando, espero que no sea del caso yo, pero se está polarizando gente que se está rezagando en las nuevas tecnologías. ¿Cómo hacer por parte de LARS y del Harriet & Society algo para reactualizarnos? Y que no se requiere el proctoraje, sino prepararnos. O sea, yo creo que la solución no es llevar un proctor a que nos ayude a hacer una cosa y no vuelvas a tocar. Yo creo que hay que retomar como educación a los que nos falta preparación, en algún centro en Latinoamérica o en Estados Unidos, de hecho. ¿Alguna pregunta de la audiencia? Sobre eso tengo un comentario. Puedo hacer un comentario sobre el tema del training. HRS ahora empezó y ha convocado médicos en Latinoamérica, una iniciativa para hacer las nuevas guías sobre el training global con la sociedad europea, con Asian Pacific y con Latinoamérica, justamente por ese problema. Creo que empieza, no sé si está Michel por acá, pero creo que empieza dentro de dos meses. Yo creo que eso es muy importante, los documentos globales. Todos sabemos que el conocimiento es único, ¿verdad? Y debe ser aplicado en todas las latitudes. El tener guías globales, guías mundiales, para hacer aplicar en nuestras latitudes, evita cosas como las que ocurren en algunos países, y yo hablo mucho con los amigos uruguayos, que tenemos mucha conexión. Es imposible que haya una regulación o una indicación diferente al resto de Latinoamérica. Lo conozco de primera mano al problema, y mi amigo Alejandro Cuesta siempre lo ha traído acá a esa inquietud. Por eso debemos tener toda esta reglamentación global. Y decir, yo lo firmo, yo lo suscribo, y esto también es para mi país, esto es para Latinoamérica, esto es para Europa. Así que vienen las guías de training ahora. Tenemos un solo minuto, si quiere alguien de la audiencia hacer algún aporte. Gracias. Okay, you can. Número uno, los costos. Nosotros no podemos ser buenos si no tenemos los recursos para serlos. ¿Cómo vamos a ser exitosos con una ectopia ventricular, con un músculo papilar, si no tenemos ice? Es casi lanzarnos al ciegas. Entonces, si no trabajamos lo que son las limitaciones tecnológicas y los recursos, no vamos a llegar a ser buenos. Y en ese mismo aspecto, las limitaciones que tenemos en Latinoamérica son nuestros números. Nuestros números todavía son bajos, entonces las industrias no van a bajar los costos, hasta que no tengamos mayores números. Entonces, si no nos unimos como región Latinoamérica, en donde todos nuestros números sean compartidos, y hablamos a través de políticas de acción o political action committees, que podemos hacer a través de Unidos con el HRS y LARGE, en donde juntos nuestros números, luego del censo que habló Luigi, pues esos números son unidad, en donde presentamos a las industrias como nuestros números más altos como región Latinoamericana. Entonces, sí, los costos van a bajar. De lo contrario, de forma individual, viendo los números que presentamos, no van a bajar los costos para catéteres de contactos ni para ice. Vamos a ser algunos pocos o algunas pocas personas que paguen privado y la mayoría de nuestros pacientes no se van a beneficiar. El segundo aspect is the aspect of education. I understand a lot why still none of the fellows train in the country. Again, the numbers. We need many cases to be able to have educated fellows in local countries and we need many years for this. Now what do we need? In Latin America we work alone, we do not have nurses trained in physiology, we do not have trained mappers and this is a huge limitation. When many of us and colleagues can do this, when we are going to make complex cases, we have to schedule this mapper that come to our center and that comes from Puerto Rico, that ends in Costa Rica to come where we do and limits our agenda. So if we do not work hand in hand, one to one, all Latin Americans with the industry, making our numbers are shared so that they know that if we are strong and that if we share the numbers then the demand will be higher, the costs will be lower and we have a better representation at the level of procedures. We do not work alone and we need mappers more than anything else before increasing the number of electrophysiologists. We have to work more coherently with what we have. Thank you very much. Last question and we move on to the break. Yes, thank you. Mauricio Hong, I work in Austin, but I am from Mexico City. Looking at the numbers, the number of defibrillators that are implanted in Latin America is minimal, so I think that something we can do right now is start doing the stimulation of the left branch in marcapaseo, which we started and I started doing it a year and a half ago, and the fraction of injection goes up. Right now I spoke, it's $3,000 less between a bicameral marcapaseo compared to a resynchronization marcapaseo and compared to a defibrillator, $15,000 less and if the fraction of injection increases with the left bundle pacing, then we are saving $13,000. It is the lead, right, 3830 from Medtronic, which is available for all of you. I think we have to start training all Latin Americans to put left-brain stimulation today, because that is available right now and this will reduce the number of defibrillators that we need. That is point one. Point two, for Chagas, my wife is an infectologist and malaria, the case of malaria, Bill Gates, the association of Bill Gates has almost eliminated it, so I do not know if HRS can talk to the association of Bill Gates for the association of Chagas, because it is something that he is interested in, that his institution is interested in making that type of contact. So, I think if we make an HRS document with Bill Gates, maybe we can have an influence for Chagas. And well, the third, in terms of teaching, I am open, right, being Latino and working in the United States, to help in what I can. I have tried to speak to Mexico, Colombia, certain countries. There are also limitations of Latin America when we offer our help from the United States, and these limitations are generally of ego, of arrogance, and I think we have to get rid of that, right, because I am open to coming fellows from all Latin America to my place, to put ... we can start the month that comes, okay, and also to send people to train in the United States, and the problem is that they go back there, right? But well, thank you. We move on to a short break of five minutes, fast, and see you again. Well, first of all, I want to invite the President of HRS. I want to introduce Andrew Clarn, he is the President of HRS. He really was a great support for us, for HRS, for Lars, and we are so grateful with him and all the effort he has been doing. Andrew, please, you have to ... Please, please, quiet in the crowd. Please, I invite you to sit down again, silence, please. Andrew Clarn, the President of HRS, will speak, it is an honor to have him with us. And I think it speaks to the partnership that we have been working on together as organizations, and I credit Fred, who will make a few comments, Fred Kusumoto at my left here, with the idea of formalizing the process of partnership and creating these summits to try to understand both the organizations, but also the process of care, and our joint interest in improving the process of access to care and quality of care, and that is through initiatives like not only technology and health systems, but education, and partnership and communication, and joint publications, and committee work together, and so on. So, I think all of these things speak to our common interest in building together, and I am very grateful also to Nestor for making about 100 phone calls to people to bring it all together, with support from Michelle and Ulysses for his role and leadership of Lars. So, the timing of this was related to when people could feasibly travel and so on, and so I'm actually in the middle of running a board meeting over on the other side. So, our board's meeting, so that's why I haven't been able to be here for the whole thing, and so Fred and I are going to say hello and then graciously try to excuse ourselves, but once again, thank you for the invitation and the opportunity to build our friendship. Fred. Yeah, just, you know, the excitement in this room is just, you know, it's palpable. It's really exciting because, you know, as Andrew just pointed out, you know, arrhythmia care is worldwide, and so this notion of trying to build a worldwide community is absolutely critical. So, last year we started with Asia-Pacific, so we had the APHRS and HRS had a joint summit similar to this, and that actually is going to come to a publication coming out in the next month or two, and I know that proceedings from this meeting will have that same sort of impact, and what is that impact going to be? Is it going to be a lot of people just talking together? No. What can happen sort of with that? With that APHRS, HRS summit, we actually have, for example, how much funding does, let's say, Japan or Singapore do for cardiac care, for medical care? What percentage of their GDP? And I will tell you, there is no question in Asia, it is really quite variable. No surprise. I think it is a similar situation in Latin America, and I think that this kind of information, this sort of evidence, Eduardo and I were speaking about it earlier, this type of evidence can put real pressure to then make real change, which then ultimately will then provide additional care, better care for all of our patients. Similarly, thinking about pacemaker implantation, which, as we were talking about, that is an emergent, but how about three-dimensional mapping, defibrillators, CRT, things like this? We have those numbers in Asia. I hope that you are going to put those together for Latin America. This type of real evidence and information can then be used to inform governments with regards to how to fund the care for their patients so that the best care can be provided in your individual country. So this is something that is not for nothing. This is something that is for something that can really impact change, and that for all of us then, ultimately, as Andrew just emphasized, to learn from each other to identify best ways to go forward. So thank you very much for letting us be here. Well, we'll start the last part of the event. And I want to, thanks, thanks. Well, the first speaker will be Alejandro Cueto from Argentina. He's the president of SADEC. After him, Juan Lopez-Diaz, president of the committee of the Argentine Society of Cardiology. After him, Gerardo Rodriguez from SOMEG. Juan Carlos Diaz, a large representative from Colombia. Armando Pérez Silva from Chile. And Fátima Dumas, president of SOBRAC, the Brazilian Society of Electrophysiology. Please, the videos. And for this, we have to present a series of documents, where there is evidence that the aspiring person has participated in the analysis, discussion and decision-making of clinical cases related to arrhythmia, has interpreted at least 500 halters, has carried out 100 tests and has also controlled, monitored, programmed at least 100 halters, 30 defibrillators and 15 resynchronizers. Apart, he must have at least participated in 100 electrophysiological studies, 50 radiofrequency speeches and have participated in the implant of 50 halters, 30 defibrillators and 15 resynchronizers. As for the offer, the presence of opportunities for training in Argentina, there are many and there are entities and various associations that give opportunities and courses. One of them is SADEC, the Argentine Society of Cardiac Electrophysiology, which is the headquarters of the University of Electrophysiology Specialist Career at the National University of La Plata and grants the title of Specialist in Electrophysiology and Step Marker. It is also done at the Universidad de la Fundación Pablo Loro and the Argentine Society of Cardiology performs the higher course in cardiac electrophysiology. As for fellowships, there are many, most of the centers offer these opportunities and mostly go to Argentina, doctors from their own country, from Bolivia, Ecuador, Colombia and Uruguay. What are the entities that group Argentine electrophysiologists? Well, the Council of Electrophysiology of the Argentine Federation of Cardiology, the Council of Electrophysiology of the Argentine Society of Cardiology and the Argentine Society of Cardiac Electrophysiology SADEC. Is there a national congress? Yes, there is the Argentine Congress of Arrhythmias, which is organized by SADEC and the Arrhythmias committees of the Argentine Society of Cardiology and the Argentine Federation of Cardiology, and it is one of the largest electrophysiology congresses in Spanish-speaking countries. The last congress, the eleventh congress, which was held last year, in 2022, had 3,160 registered, mostly doctors from 10 countries and mostly women. What are the scientific activities of SADEC? Well, participation in multiple webinars, Navigators and Intracardiac Echography courses, Annual Course for Technicians in Step Markers, Defibrillators and Resynchronizers, Electrocardiography and Holter Courses, and joint activity with the World Association, the Argentine Federation and the Argentine Society of Cardiology. There is no gremial activity or direct relationship with the government. As for the availability of technology in the Argentine Republic, there are multiple 3D mapping systems, both from Abbott, Johnson & Johnson, and Microport Everplace. There is also the availability of cardiac echography, but it is mainly carried out in patients who have private health insurance, less in patients who have social and gremial insurance, and in a very small number in public hospitals. What are the activities in the development of Argentina? Everything related to the implantation of step-markers without cables, physiological stimulation, and the use of OREJUEGA occlusives. Thank you very much. My name is Juan Cruz López Díez, and on behalf of the Argentine Society of Cardiology, I am going to talk about the medical system in Argentina. The Argentine health system is made up of three subsystems. These are public health, social security, integrated by national, provincial, and retired social works, and pre-paid medicine. The public health subsystem provides universal and free health coverage in hospitals and asylums, to which every citizen has the right to access, regardless of whether they have other types of coverage, such as social work or pre-paid medicine. Its financing comes from taxes collected at the national, provincial, and municipal level. In the public system, there is no defined and homogeneous benefit plan for the different hospitals, so the supply of health services depends on the availability of health personnel and their specialties, equipment, supplies, available beds, availability of shifts, etc. The availability of these resources is very variable throughout our extensive territory. In many regions, it is usual for the demand to exceed the supply because there are huge delays in the granting of shifts or lack of specialties in some establishments. The public sector is used by approximately 36% of the population, and these are people who do not have other types of coverage. It is remarkable that in this system foreigners are treated, even those who are not naturalized, for free. Social work. Social work in Argentina is an entity that provides medical care to workers in a dependency relationship. They can be state or private, although the vast majority depend on trade unions. Social work is equivalent to the medical insurance of other nations. By law, all employees in a dependency relationship must have medical coverage, and for this reason the worker and the employer are obliged to pay a percentage of the salary for this purpose. Social security is the main source of non-governmental health coverage in the country. There are almost 29 million people, which is equivalent to 63% of the population. The private system or prepaid medicine. Prepaid medicine companies are private medical institutions for profit, used by a sector of the population that can absorb the cost of a monthly fee. 13.6% of the population enjoys this luxury. As you may have noticed, the percentages exceed the total population, and this happens because there is a superposition of coverage with people who have at the same time the benefit of provincial and national social security or social and private security, since the different health subsystems are not articulated together. I mentioned initially that in the public system there is no defined and homogeneous benefit plan for the different public health hospitals and establishments. Now, social workers and prepaid medicine companies have the obligation to comply with the benefits established in what is called the mandatory medical program or PMO in Argentina. This contains the set of medical benefits that every beneficiary of social security and everything associated with prepaid medicine has the right to. That is, it constitutes the set of mandatory medical benefits that, as a minimum floor, should be provided by health insurance agents and prepaid medicine companies. The PMO guarantees to have covered 40% of the cost of ambulatory medicines and 100% of medicines in hospitals and oncological medicines. In conclusion, Argentina has outstanding health virtues as inclusive principles through universality with respect to coverage. However, serious flaws are observed in the facts. Nowadays, access to health is not guaranteed in many places in the territory, and when it is, the quality of the service is not homogeneous, as it is determined by the purchasing power. This is because the health system is strongly fragmented, generating a lack of coordination that dilutes the responsibility when it comes to providing coverage. The PMO seeks to grant equal coverage guarantees to any beneficiary. In practice, social workers have differences in issues such as the administrative attention provided, the availability of shifts, the offer of professionals and the closeness of beneficiaries with care centers, which generates that there are different qualities of the service that, as always, are reflected more intensely in the sectors furthest from urban centers and with lower economic resources. Thank you for your attention. Mexico is complex. There is a public system and a private system. The private system serves about 10% of the population through insurers, and the public system serves the rest of the population through three large systems. There are times when the private system and the public system collide, and within the public system there are people who have two or three different insurances. The largest system is the IMSS, which is the Mexican Institute for Social Security, which is based on contributions from workers and government contributions. It serves about 70 million civil servants. The ISTE, which is the Institute for Social Security at the Service of Workers, serves 14 million civil servants. The Armed Forces, which are the Army and Navy, serve 1.5 million. And the Ministry of Health has now incorporated a new system, which is the IMSS Welfare, which is also from the Ministry of Health and serves 40 million civil servants. Some people have two or three insurances between the IMSS or the Armed Forces, ISTE or the Ministry of Health or even private media or systems. Within the private health system, what do we have? Well, the insurance policies, because the minority of the population can pay for procedures, and especially complex and expensive procedures such as electrophysiological procedures. There are around five different policies or more, so that's complex because we don't know what the insurer is going to charge, to cover in their policy, and how much the medical fees will be. So the coverages are different. The procedures can't be added either, you can't add the function with the transeptal function, with echocardiography, etc. They only catalog a single procedure. And also, these medical fees are undervalued. There is no official rector in all the country. Every private hospital is governed by its own individual rules. And also, the country is very heterogeneous. The population has a different purchasing power. It's not the same in the south, in the north, in the center, and it's not the same in the border states either. So the high specialty is generally concentrated in urban centers. But there are states that are important, like the state of Veracruz, that doesn't have an electrophysiologist in the whole state. So you have to go from outside to do the procedures. As for the public system, the public system has three fundamental problems, which are fragmented and dispersed. There is a brutal administrative bureaucracy, and the problem of salaries. It's fragmented and dispersed because there are three big health systems, but each state can have its own health system for the workers of that state. So this gets very complex because there can be ten different health systems. And there is no coordination or joint plans between each system. Here we are going to see it. The IMSS, the Health Secretariat, which are the largest organizations, have independent directives and do not have mutual collaboration. That's why the Health Secretariat, which should govern the country's rules, doesn't do it. The high specialties are also concentrated in a few centers, and there are some centers where electrophysiology is not recognized as such. We have a name as hemodynamists, not as electrophysiologists. And there are also few electrophysiologists at the national level, approximately less than 200. And not all electrophysiologists perform the same procedures. The administrative bureaucracy in all of Latin America is brutal. The transfer to the high specialty reference centers is complex, and the indicators are not based on the quality of the care, but on numbers. Numbers such as if you attended a patient in less than a month, but it is not seen if you solved the problem, the number of days of bed is not counted, and a patient can be hospitalized for a month, waiting for a pacemaker to be bought. The budgets are labeled and individual, they cannot be mixed. We can have supplies for a desynchronizing walker, but we cannot have gauze or antibiotics. Finally, the salary and benefits. Each health system has different salaries and benefits. The best is the IMSS, which is the Mexican Institute of Social Security, and the worst is the ISTE, the Social Security System at the Service of State Employees. To give you an idea, the salary of a month in a public site like the ISTE is equivalent to performing a procedure in a private way, a placement of pacemakers in a private site. So it is very complex because there are places where they do not want to work in the public system, despite having cardiologists or electrophysiologists, like at the border, because the retribution is very low and there is a lot of paperwork. Finally, I want to say that despite all the restrictions we have, there is a success in the treatment of arrhythmias in Mexico, and it has evolved in the last 10 years. Everything is done at an international level. Ear inflation with cryo and radiofrequency is done, physiological stimulation, resynchronization, walkers, simple and complex conversations with the CARTO system, zero-fluoroscopes or with the ENSITE system, ventricular tachycardia, etc. Despite the shortcomings, we do have equipment and we can carry out studies satisfactorily. Thank you very much. Good afternoon, everyone. My name is Juan Carlos Díaz, I am an electrophysiologist from Colombia, and the idea is that we are going to talk a little about the Colombian health system and what are the challenges of electrophysiology in Colombia. I have no conflict of interest for this talk, and the idea is that we start by talking a little about the Colombian health system. Currently, we have three regimes. One is contributory, which are those people who have a monthly salary and we give part of our money to contribute to the health system. Another is subsidized, which are those people without the ability to pay, who in theory have the same benefits and the same rights as those who pay for the health system. And there are special regimes that are part, for example, of teachers, psychiatrists and military forces. There are several actors in this. One is the government, which sets the policies and how the payment will be for each year of the health system. The health care providers, which are basically the insurers who will manage the money that the government gives them. The health care providers institutions, which are the clinics and hospitals that will contact those health care providers and health professionals, who are the ones who will end up providing the service. The health spending in Colombia is relatively high, it is approximately 8% of the gross domestic product, and the spending in the pocket is minimal, with almost universal coverage, with what we call the basic health plan. This basic health plan includes 97% of all available technologies in Colombia for all areas of medicine and 89% of medicines. This in electrophysiology translates into the fact that we have the possibility, through this basic health plan, of conducting medical consultations and device interrogations, implanting any type of device. In addition to that, all electrophysiological procedures, including conventional studies and three-dimensional studies, and it does not cover remote monitoring, which is a felt need that I think we are all having at the moment. At present, we are 64 members already in the Colombian College of Electrophysiology, there are three that are in the process of entering, and there are 10 electrophysiologists who work in the country who are not and are not part of the Colombian College of Electrophysiology. As you can see, the vast majority of electrophysiologists work in large cities, such as Bogotá, Medellín, Cali and Bucaramanga, with a lower representation of what is the interior of the country, towards the coffee plant, the south of the country and the Atlantic coast. How is the process to become an electrophysiologist? Well, first you have to have three years of internal medicine, subsequently two years of cardiology and subsequently two years of electrophysiology. And this applies both if you are trained in the country and if you want to complete an external degree. The completion of an external degree requires that it be a degree given by a university and that these requirements are met in the training program. The vast majority have been trained in Colombia, with some people trained in other parts of the world, but in Colombia we currently have three training programs, one in Medellín and two in Bogotá, which will end up graduating approximately six fellows each year. What do these fellows train in? Well, they train in devices, in conventional studies, that is, those with a fluoroscope, and in procedures with three-dimensional mapping, such as, for example, the isolation of pulmonary veins, the ablation of ventricular tachycardia, atrial and ventricular extrasystoles, or atrial tachycardia. That is, fellows in Colombia train in practically all the procedures that we can currently do in electrophysiology and have good training compared to fellows from the rest of the world. What are the future challenges? I think that this first challenge that I raise here is a challenge that is common for everyone, and particularly in Latin America we have to take the step forward to modify it, and that is to increase the representation of women in electrophysiology. There are many fears among women. For example, the exposure to radiation. We have to explain from the basic training programs that many of the procedures we currently do with minimal radiation or even without fluoroscopy. We have to facilitate spaces for those women who are head of family or who have children. We have to make a change in the attitude of some teachers who still consider that electrophysiology is not an area for women. We have to expand the service in intermediate cities, and in addition to this, we must initiate telemedicine programs that allow all these areas that do not have electrophysiology to provide highly specialized and quality care. Thank you very much. Good afternoon. My name is Armando Pérez Silva. I am a cardiologist and electrophysiologist at the Regional Hospital of Concepción in Chile. I would like to thank L'Arche and HRS for this kind invitation to share a little of our regional experience. Well, I have nothing to declare. Chile is located in the south of South America, adjacent to Argentina and Bolivia and the North Atlantic Ocean. It has a particularly very different geography from the rest of the region, with deserts in the north and very cold climates in the south. And given this particular geography, many of its health policies can be explained. It is important to remember that it occupies the 33rd place of almost 200 countries in better health quality, and can be compared with many countries in the Iberian Peninsula. It invests an important part of its gross domestic product in health, one of the highest in the entire region. It is estimated that this investment is around 9 to 10%. And it is managed by a national health system, called FONASA, which is in charge of compliance and monitoring of specific health policies. It is also estimated that two-thirds of the population are within the net public system, and only less than a third are in the private system. The life expectancy in Chile has grown in recent decades, being low in the mid-1950s, to be at this time the highest in South America, and is expected to be the highest in the continent by 2100. And this is mainly due to several policies, but the most important of them, and the ones that affect heart rate alterations, are the GES pathology and another call for emergencies. The GES diseases are a set of 87 pathologies, which include from pneumonia to different types of cancer, where heart rate alterations are included, bradycardia, tachycardia, step-marker implants of all kinds. And these guarantees, these types of pathologies, and this law, make any patient who has any of these diseases, it is the obligation of the state to comply, to follow up, and also in a pre-established period of time. And the law of emergencies is a law that is applied in other parts of the continent as well, but what it tries is that any patient with a life-threatening disease, regardless of their condition, public or private, or regardless of the type of health system they have, the closest public or private health center must solve the pathology in a complete way. As I said before, all bradyarrhythmia problems, specifically step-marker implants of any type, occur practically throughout the entire geography of the country. This is an important point with respect to other countries in the region. We are clear that in many places in the South American continent, there are countries that simply do not have access to a step-marker implant. Here in Chile, it is very difficult to say that a patient dies or dies due to a lack of a step-marker implant. That is, anywhere it can be derived from a nearby region or in its own region, and a step-marker is implanted. Not so the alterations due to tachyarrhythmias or complex arrhythmias, or patients requiring defibrillators, resynchronization, or conversations with a navigator. Here, almost two-thirds or more of all these pathologies derive from a very small area of the country, which is the central area and the south-central area of the country, where almost all the procedures derived from other health centers are carried out. This is mainly due to the lack of development of complex hospitals in the very extreme areas of the country. As a conclusion, I must say that Chile is developing as a country with promising and innovative public health policies, but the geographical accident, the low population density in the most extreme areas of the country, desert and cold in the south, and coupled with the lack of specialists in these regions, has been a substantial limitation for complete development. Thank you very much for your attention. It is my pleasure to be part of the Latin America Summit 2023. My name is Fátima Cinta and I am the current president of the Brazilian Society of Cardiac Arrhythmias. My task today is to talk about health policies issues in Brazil and I will focus on challenges of healthcare systems, workforce and training. Brazil is the largest country in South America and also Latin America, with over than 214 million inhabitants. It is divided in five regions with great differences, not only in ethnics, culture, but also in health aspects. The current structure of Brazil's healthcare system is called Sistema Único de Saúde and was implemented in 1988 and established health as a universal right for the whole population with three main principles. The first one is that universal rights include all levels of complexity, primary, secondary and also tertiary. The second one is decentralization, thus involving federal states and municipal governments to provide health. And the third one is a great social participation, not only in formulating, but also in monitoring the implementations of healthcare policies. Nowadays, the private healthcare becomes an important pilot of sustainability of healthcare services in Brazil. It is responsible to serve more than 23% of our population that corresponds to more than 15 million Brazilians. It becomes an alternative for obtaining healthcare services and it gains attention not only by the amount of service offered, but also by the quality of care provided to its users. There are three main ways to have access to private healthcare in Brazil. The first one is personal health insurance. The second one is a company health insurance for those who are employed by a great company. And the third one is a professional association health insurance. It's kind of personal health insurance, but with a very attractive price since the negotiation is made by a great number of users. It's clear that the public service represented by Sistema Único de Saúde will not be able to meet the demand of medical care in Brazil. So it's expected great challenges in Brazilian healthcare system. The first one is inequality in access to health. We can deny that many measures of healthcare systems performance in Brazil have improved since SU's implementation, but again have not been equal across the population's group. Another point that should be highlighted is a great demographic transitions. Life expectancy in Brazil increased from 70 years old in 2000 to almost 76 years old in 2019. It's a good result, but it is still some years, remains some years below when compared to similar countries. Access to highly complex procedures in Brazil is the main challenger, especially those related to cardiac arrhythmia. According to Brazilian mortality information system, from 2080 to 2019, there were over 350,000 hospitalizations for atrial fibrillation, but only 1430 ablations procedures for AF performance by SU's. And despite the great reduction observed during pandemic, we currently have about 20,000 spacemakers implantations and 7,000 electrophysiologist procedures, far below what would be expected. It is also important to address material reprocessing, and at this point requires a more comprehensive discussion. In Brazil, reprocessing EP materials is heterogeneously managers across different states in the country. And although federal regulations allows reprocessing, there's a lack of national protocols, structure, and data that indicates safety of this practice in the country. I hope I have clarified some important points of the Brazilian healthcare system, and thank you very much for your attention. We'll speak from Uruguay, Alejandro Cuesta, large representative, after him Eliani Mejia from Dominican Republic, in representation of the Peruvian Society of Cardiology, Ricardo Segarra, and then Ana Gonzalez Luna from Peru, and Eleodoro Rodriguez from Venezuela, in representation of the Venezuelan Society of Cardiology. To end, from Salvador, Marta Reyes, and Elibet Chavez from Cuba. Our healthcare system has been integrated for 15 years, it is at national level, it is based on four basic principles of sustainability, universality, equity and quality. Sustainability is determined because this is organized by the government, by the Parliament, and the pillars are the Ministry of Health, the Ministry of Economy, the Ministry of Economy providing sustainability, responding economically to the system, and the Ministry of Health as a health authority, ensuring and supervising quality. This national system integrates all public and private actors. Some are very small systems that go out, such as the military system, the police, the university hospital and the national mobile emergency system. The National Integrated Health System has, on the one hand, its governance and financing. The governance is given by the National Health Board, which is integrated by the Ministry of Economy, the Ministry of Health, employees' delegates, employees' delegates, employees' delegates and users' delegates. This is the political control of the system, which is administered by the National Health Fund. This National Health Fund feeds on the contributions of all workers, of all employers, also of retirees and state contributions. In addition, there is a sub-fund, which is for high-complexity and high-cost procedures, which we will later extend. This National Fund is the one that finances the integral providers through capital, that is, it pays them a fixed amount per affiliate, according to the sex of the age, and it also pays them according to certain benefits goals, for example, breast cancer screening, colon cancer screening, maternal lactation, etc. This is done through a contract. The National Fund makes a management contract with the integral providers and there it is forced to lend a basket of health benefits and a basket of drugs, which is roughly the vast majority of the benefits, but not all of them, if it is the balance sheet of our system. It also receives other lower income from contributions by tickets, from some private insurance quotas and from the sale of services. And then there is that smaller sub-fund, with the exception of the high-complexity procedures, which are less frequent and more expensive, which also establishes what are the mandatory benefits. And here, as I will tell you later, most of the electrophysiology procedures should be included. Users who opt for the public system do not pay anything at all. Those who opt for the integral providers of collective assistance only pay tickets. Those who opt for private insurance have to, in addition to repaying the tickets, a surplus above the capital that the National Health Board gives to the company. And the benefits of the National Resource Fund, for example, a heart transplant, a cardiac surgery, a defibrillator, for this they do not pay anything and it is universal. It covers 100% of the population. Everyone has the same rights and obligations within that framework. So, of the Uruguayan population, 39% opt for those integral providers to attend the public system, because there they do not pay tickets. Only 1.8% behind private insurance, because there they have to pay a surplus. And 57% or 60% of the population attends the system of collective companies, which are usually co-governed, in which only tickets are paid. And the quality is an intermediate quality among the other two subsystems. And regarding the procedures that are done in the highly specialized medicine center, the user, regardless of where he or she belongs, the user chooses in which IMAE, in which high-complexity center, he or she wishes to attend. Well, I hope that in this scheme, more or less, it has been clear to you how it works. I imagine you have doubts, I'm sorry not to be there, but Dr. Marino can probably evacuate. Thank you very much. Good afternoon, I'm Ulyani Mejia, menocardic electrophysiologist, and I'm following the presentation of my colleague, and I'm going to be talking about the political issues. We have five major problems that we're going to be discussing. Access to health care services, training and education, insurance coverage, integrated societies for electrophysiology, and standardized guidelines and protocols is the last one. Number one and major problem is the access to health services. In our country, approximately 30% of the population in the Latin American and the Caribbean do not have access to health care because of economic reasons. 21% do not seek care because of geographic barriers. In the same token, our country, as many others in Latin America, has advanced economically in the last decade. And along with this increase in globalization, the lifestyle of the people have changed. Life expectancy is higher, and with that comes an increased burden of disease resulting from chronic and non-communicable diseases, such as hypertension, diabetes, cancer, and obesity. When we talk about this, we have to talk about the health spending in Latin America and the Caribbean. And compared to all other countries, Dominican Republic is right in the middle. We are not at the top or not at the very bottom. But even with this, we're still lacking resources in order to provide appropriate health care for our population, which lead to inequalities and inequities in health care, with a significant percentage of the population at the base of the pyramid. This means that many sections of the population are often at higher risk, as health care problems are often influenced by social factors, such as education, sociocultural level, income, and ethnicity. Third major problem is straining education and distribution of human resources and health. Our country still does not meet yet the international indicators, such as number of doctor or nurses per 10,000 people or hospital beds available for 1,000 inhabitants. People are often concentrated in capital cities or in a few geographical areas, leaving groups outside of these areas neglected. The problem is not only the lack of resources, but also a poor distribution of them. In this same token, this training and education translate into a lack of ancillary staff. And we see doctors in our country very often working as individuals and not as a team, lacking the ancillary staff needed to improve efficacy and safety. We lack nurses and techs training in cardiology and specifically in electrophysiology. Number four is a major problem, and it's insurance coverage. We currently have an old catalog of services that is not updated with the latest technology in cardiology, which harms the EP field development in our region. High power devices such as ICDs and CRTs are not currently covered. The same for treatment mapping system, eyes or contact forces catheters. And this translates into a high out-of-pocket cost for our patients and limited the care of this patient, which in terms results in increased multiple procedures or hospitalization because these patients did not have the treatment that they actually needed on the first place. And this is specifically the lack of coverage for high power devices is important and particularly striking because not even for secondary prevention, ICDs are covered in our country. And the problem is that the financing of health system. Currently, we have a system that finance their health services based on illness, which means that resources have to increase as more people get sick. This mechanism becomes unsustainable because it encourages a system based on disease and not health. And for that reasons, over the time, the system as well, the resources will always be limited. We are working together as an integrated societies in electrophysiology with the creation of protocols and guidelines and appropriateness criteria for diagnostic and therapeutic procedures in EP. We're working to do and we aim for a standardization of all EP labs in our country, creating a unifying force to advocate for our patients. And how we can meet these challenges? We have to integrate three areas, political, social and economic areas in order to improve the health care in our country. And this is going to be divided in three major areas. Primary prevention, secondary prevention and early intervention and tertiary prevention or response that this is where electrophysiology lands. Thank you so much for your attention. Thank you. Hi, everybody. Thanks to HRS and labs to inviting me to participate in this Latin America Summit of the Heart Reading 2023 session. I am Ricardo Segarra, EP cardiologist from Lima, Peru. I'm going to talk about cardiac EP health policy in Peru. The cardiac EP started in 1998 at the Guillermo Menana Hospital in Lima, Peru. The beginning was challenging, but the experience was progressively richer. In the following years, new EP cardiologists were beginning to work at different hospitals in the country. At the moment, we have in my country four independent health systems. One of them is a Peruvian Ministry of Health. Another one is a social security health system. Other is a military and police health system, and finally, private health system. For now, we are 24 EP cardiologists for 32 million people in the country. And most of them are working at the capital in Lima, Peru. All EP in Peru were training outside the country. And the EP certificate is going to be approval for the health national authority. We are making all conventional and complex EP procedure using all the tools on the market, Including multi-electrode mapping catheter, contact for ablation catheter, and intra-cardiac echo. We don't have EP society. But, extended, the Peruvian Society of Cardiology has an EP council responsible for all scientific activities. Finally, ladies and gentlemen, I will say, the EP is increasing in Peru. Local EP training, more EP lab, coming soon. Thanks for your attention. Thank you. Good morning. First, I would like to thank you for the invitation. My name is Ana Cecilia González Luna. I will talk about health policies in Peru. Currently, Peru has approximately 33.7 million inhabitants, 78.5 concentrated in urban areas, and we have approximately 30% of the population in poverty. Among the basic indicators, life expectancy at birth is 77 years, and among the main causes of mortality, we have cardiovascular diseases that occupy third place. The demographic transition over the years, we see how it has been decreasing the pediatric population with an increase in the adult population. The main diseases, such as hypertension, diabetes, overweight, and obesity, are highly prevalent in our country. The rules that govern the health sector in Peru, currently, we are based on the political constitution of 1993, in which it is established that everyone has the right to the protection of their health. In 2009, the framework of universal health insurance was published, and in 2019, the emergency decree that seeks to close the gap of the population without health insurance coverage, seeking to affiliate the population regardless of their socioeconomic condition. The current financing in Peru is intended for total health spending, approximately 5.2% of GDP, far below other Latin American countries. However, this percentage has been increasing both in the public sector and in the private sector. The budget allocated to the health sector is approximately 11.5% compared to the general budget. And cardiovascular diseases are among the main diseases with the highest spending in health services. How is the health system composed in Peru? Its main director is the Ministry of Health. The Ministry of Health is divided into two large groups, the public sector and the private sector. The public sector is made up of the integral health system, which is subsidiary and semi-contributive, and social security or health, which is contributory for dependent workers, who contribute approximately 9% of their monthly salary. The third group is that of the armed forces and police. The private sector is made up of the health service providers and private insurance. It is important to mention that in the public sector, health coverage is total. The coverage at present, we have approximately 78% of the population has some kind of insurance. The vast majority, almost 48%, are affiliated to the integral health system and 25% to the social security system. Almost 20% of our population does not have any kind of health coverage. The adult population, approximately 89%, has some kind of insurance and almost half of this population is affiliated to the integral health system. We are approximately 44,000 doctors. The vast majority of health professionals are concentrated in Lima, which is the capital of the country, and in the big cities, where the percentage of poverty is lower. Approximately 77% of doctors focus their attention on the two highest levels of wealth. Approximately, our health establishments, in the vast majority, are medical centers and health centers, and a small percentage are institutes and hospitals. We have complex hospitals, only 57. What are the main health problems? Lack of staff, lack of competition, there is a poor distribution of specialists, lack of medicines and supplies, many times the teams are underperformed, and lack of protocols. Thank you very much. Thank you very much. I would like to thank HRS and LARS for allowing me to participate in this Latin American Summit 2023. We are going to talk about health policies in Venezuela, fundamentally related to heart rate changes. For everyone, the important social and economic crisis that our country has suffered in recent years, which has had a repercussion in the health sector, and therefore in everything related to the management of heart arrhythmias. The Venezuelan public health system, which serves 90% of the population as a result of this economic crisis, has deteriorated and has significant shortages. On the other hand, patients who go to the private health system depend on their own resources, private medical insurance, and medicines from family members abroad. We do not have up-to-date and reliable information on cardiovascular mortality and morbidity, and specifically on heart rate disorders in our country. It is important to remember the profound demographic change that our country has had in recent years. It is estimated that more than 4,700,000 Venezuelans have emigrated. It is the only country in Latin America that has had a decrease in its population in recent years, and within this group of emigrants, we must highlight, related to the topic we are discussing, that 30% of well-trained and qualified electrophysiologists who made a professional life in our country have also been part of this group of emigrants. All this is related, of course, to the profound economic crisis associated with the decrease in oil production, which went from 2,800,000 barrels of oil per day in 2015 to less than 700,000 barrels of oil in 2021, which, fortunately, in recent months has been increasing production and we hope that the economic indicators of the crisis will improve. I think it is important to take a picture of what 2015 was like. We had three-dimensional facilities. Public employees at that time had wide insurance policies provided by the state, which provided coverage for electrophysiology and high-cost device implants. Another percentage of the population had insurance that allowed them to access these therapies. Currently, there are only two CARTO 3 browsers and a CARTO 3 version 7 Prime system in the city of Caracas. Public employees have policies with lower coverage. However, in special cases, the Venezuelan state provides assistance to carry out procedures and a smaller percentage of the population has wide coverage insurance. In 2015, primary prevention of sudden cardiac death was carried out on a daily basis, according to the guidelines of the guides. There was a wide supply of antiarrhythmic drugs and at least 10 public centers in the main cities of the country carried out invasive electrophysiological procedures. Currently, the Ministry of Health is in charge of supplying the devices that can be implanted in the public sector. However, the number of high-cost fibrillators and resynchronizers implants has decreased. The supply of antiarrhythmic drugs is much more limited than it was years ago and only two centers, exclusively public, carry out talks by the private and mixed sector. More than 20 institutions carry out invasive electrophysiological procedures. So we can conclude that in Venezuela there is currently no reliable and updated information on mortality and morbidity of arrhythmic disorders that allows strategies to attack these pathologies. The available data comes from opinions of a group of experts and some fundamentally public institutions, as well as the extrapolation of bulletins issued in previous years. These shortcomings constitute a barrier for strategies to solve these problems and the Venezuelan state has to give priority to the budget of the health system and the Ministry of Health must provide true and up-to-date epidemiological information so that together with non-governmental entities and scientific societies we can implement actions to optimize the care of the population. Thank you very much. Hello, I greet Marta Reyes, electrophysiologist from El Salvador. Thank you for the invitation to this Latin American symposium. I am going to talk a little about the health system in El Salvador. We have only three qualified electrophysiologists, that is to say that our certificates have been authorized by the Medical School and by the Superior Council of Public Health of El Salvador for the exercise of electrophysiology. There is no such thing as an electrophysiology society due to the small number that we are, but we are together within the cardiology association within El Salvador. There is no training program for the training of cardiologists or electrophysiologists, so we have all been trained abroad. We have a team for the realization of electrophysiological studies, diagnostic and conventional speeches. We do not have a three-dimensional or intra-cardiac navigation system. The health system is distributed in three sectors. Within them we have the public system, social security and the private health system, of which we will detail each of them. Within the private health system, 5% of the population is attended. We have those patients who have a private insurance, either with national or international coverage. The payment will depend on the quota that each of its policies contemplates. And we have these patients who cancel 100% of the consultation and procedures, who do not have any kind of private insurance. In this sector, most electrophysiological studies and speeches are carried out, since they do have coverage. And of the devices, they also all have coverage. We implant step-markers. We have carried out three hysian implants. They also include defibrillators and cardiac resynchronizers. Within the social security system, approximately 20% of the population is attended. The payment that each of them makes is according to the monthly payment of their salary. And it has coverage for medicines and some procedures. In social security, electrophysiological studies and speeches were carried out for several years, but at this time they are not being carried out due to damage to the equipment. Within the devices, mainly step-markers and very few defibrillators are implanted. This is the sector that is working on a project for the acquisition of a three-dimensional navigator. In the public system, the largest percentage of the population is attended. However, there is no coverage for the implementation of electrophysiological studies. And within the devices, only step-markers can be implanted. Thank you very much. I would like to thank the Latin American Summit 2023 for the opportunity. Now we are going to present the topic B1 related to health problems and health policies. To be approved in our work as electrophysiologists, at least one of the specialists in the centers that exist in our country has been trained abroad. One of them in Buenos Aires and another in Madrid, Spain. From a theoretical and practical point of view, we have received support from Dr. Luis Barja, who has received the sponsorship from Abbott and Biotronic. He has come to our country since 2015. For 15 days, twice a year, to Havana and the city of Santa Clara to train the groups of electrophysiologists in these two provinces. We have also received support from doctors from Brazil, the United States, as well as technicians from El Ensaite, from Colombia. The qualification of the rest of the professionals is from courses of diplomas approved by the corresponding universities of Havana and Villa Clara. A course that lasts a year and graduates with a diploma certification. There are no university degrees in our country. Once these diplomats have graduated, they continue their work in centers where there are also professors who already have experience in the implantation of step marks or electrophysiology in the other centers of our territory. As for the implantation of heart devices, the devices are implanted in 13 provinces of the national territory. And in three of them, marked in red, which is the province of Havana, Villa Clara and Holguin, heart defibrillators and resynchronizers are also implanted, where there is qualified staff for this task. In the 13 provinces of the country that have implantation centers, there are a total of 19 implantation centers, 5 in Havana, 2 in Villa Clara and 2 in the province of Seville. The rest of the provinces have a per capita center. Here I show you a work that we have published in 2008 in the magazine Archivos de Cardiología de México, where it is shown that we have been working on stimulation in alternative sites such as the septal region to avoid heart dissynchrony. And in our country, we have developed this technique without having the necessary tools of the implantation center. We have two electrophysiology centers in Cuba, one at the Institute of Cardiology in Havana and one at the Ernesto Guevara Cardiocenter in the province of Santa Clara. At the Institute of Cardiology in Havana, we have developed this technique without having the necessary tools of the implantation center. At the Institute of Cardiology in Havana, we have an Enzyme Velocity and a Radiofrequency Cubic. These are the arrhythmias to which we give the ablative treatment, but we must mention that at the moment the Enzyme Velocity is not working for the reasons that we show here, and the Radiofrequency Cubic is working. We do not have intracardiac echocardiography in the country. At the Villaclara Cardiocenter, we also have a Radiofrequency Cubic, and the ablation of this type of arrhythmias is being carried out. Observe here the ablation of ventricular arrhythmias with the Radiofrequency Cubic in the city of Santa Clara. Here, an ablation in the region of the posterior ring of a ventricular tachycardia. In the region of the tip of the right ventricle. And finally, this one that we show here, the ablation of a ventricular tachycardia fascicular idiopathic posterior of the left ventricle. The Cuban Society of Cardiology organizes scientific activities at the Institute of Cardiology generally once a year, and also at the Cardiology Congresses, which are organized by two of them in the country, one of national character and the other of international character, which increases the knowledge of electrophysiology in the cardiologists and electrophysiologists of our country. And here I show you a panoramic view of the beach of Varadero in Matanzas. Thank you very much. We can start in Spanish, if you want, so that more people can participate. Well, we see a disparity in health systems in the different countries. There are places where most of the health is done in a private way, paying in cash. We see this reality in countries like Bolivia. We see others where there is also a very large disparity in health systems, and it is sometimes very difficult for people from the United States, from HRS, to understand each other. So, I don't know. People from Brazil, what do you think? Mexico? What are you thinking? How can we, as LARS, help in something like this? I don't think so, but... What do you think? Well, I will speak in Portuguese, so that you can understand me. I think it is a very complex problem. We have a common denominator in all of Latin America, which is... Everyone talks about problems with infrastructure, training, equipment, industry, costs. We all have the same problems in different intensities. I was here listening to the lectures and thinking that it is like a critically ill patient. They don't have just one problem, they have multiple problems, multiple organ failure, and they need an integrated approach. It is no use saying that we will put in Cuba more than 200 electrophysiologists who will not solve the problem. We have to have an integrated government that listens to doctors and specialists who want to invest in health. These are broken governments, all with financial problems. I don't have the solution to all the problems, but I think the message I get from listening to everything I heard today is that we need an integrated action. LARS can be a link for integration between several countries. We can pressure the government with the support of HRS, with the support of scientists, so that we can pressure governments and the industry so that we can gradually improve our numbers, which are really very low compared to the rest of the developed world. I would like to say that we all know that our governments are not ideal. They are a necessary evil. But we need them. At some point we have to interact with governments and we have no choice. Some are worse, some are better in Latin America, but that's how it is. Here is the question for Ana, for José, for Marcio, for all of you. And that is the objective of this, to try to see how we can help or how we can organize ourselves through society, through LARS, with the help of HRS, which, as you can see, we are now trying to join efforts in many things. So the question is, how do you see it? What do you think we need and what can we do as a medical society to be able to develop and advance a little faster in the development of our activity throughout Latin America? Well, I think it is indeed a serious problem that all Latin American countries are suffering from. The inequality in how resources are distributed, I mean, in greater or lesser proportion, we all suffer from this problem. And like many things in Latin America, we are used to doing the best we can with what we have and optimizing resources according to the realities we have. And in this sense, well, in Mexico it is very common, for example, that we reuse material, catheters, devices have also been reused, donated by people who die, and here we have scientific evidence that this is a practice that is not harmful for our patients. And I think that through LARS and our societies what we can do is give this support, this scientific support to these practices, which, well, are not entirely orthodox, but which do not harm our population either, and that, in a certain way, we are a little forced to carry them out to be able to benefit our patients. So, well, in the same sense that we mentioned a while ago about registrations, censuses, I think it is also important to publish these experiences that are probably spread to several countries in Latin America. I also think, as I mentioned before, that the issue is that I think that we as a society have to listen to people, because I saw that, as you said, in different countries there are different realities. So, I think that, for example, in the countries… I want to take advantage of the opportunity that HRS is giving us with this summit. For example, in countries that have difficulty training electrophysiologists, we could be a bridge for that. I think that HRS… that is an important thing for HRS. I don't know how HRS can take advantage of some HRS force to incorporate technology. I have no idea how it can be done. But, yes, to be a bridge for training, for people, that's for sure. That could be done with the help of society. Society should also listen to its partners. I think that we should always be open or always ask how we are doing now, what are the needs, and maybe help someone who needs it with someone who can give, for example, with training. But I also think that it's very important to have a record, to have statistics of procedures, of centers, of devices, because that's very important. I think that maybe, with the help of HRS and with the support of the industry, because that has a cost. I know that it can be done in other ways, but anyway, that has a cost. So I think that's also very important as a plan for the future. Here in the panel is José Moltedo, who is a privilege for us in Argentina to have a pediatric electrophysiologist trained abroad. And I think that such an important sector of young people doesn't have the backup, the support of electrophysiology that Latin America should have. I don't know, José, what would you say? Thank you for the young man thing. I'm not that young. No, actually, I, listening to the issues that we have in the region, I would like to make a self-critical statement, if you will, of LARS society. I think that we should all, as a community, look for a more effective way to get there. I think there is a bit of disconnection between what society does and reality in the different countries. And I think it's related to problems in internal communication and how we communicate. I heard at the end of the first session about the need to make a diagnosis about the situation or the status of electrophysiology in Latin America to be able to know the nature of the problem and, from there, articulate potential plans to solve the problem. Well, we, from the Pediatric Committee, two years ago, published in scientific journals the current state of pediatric electrophysiology. And I don't know if that was communicated in the way it should have been communicated and if it was given the value that it should have been given. And I belong to society and I'm in the Electrophysiology Committee and I feel that sometimes the arrival is not the most effective. This type of event may be useful, but it is also true that we are few, or relatively few, Latin American doctors who come. So, I think that, from LARS, we should consider in what way we can arrive better, communicate better, open up more the functioning and the decisions that are taken to be able to address the problem in a more efficient way. Well, we all know the problem. We saw that everyone has a different problem. How do we react? Why should we react? If we stay with this, they will follow us. We are dead. This is also a political problem. Health policy. So we have to attack from that side as well. If we don't meet, there was an Argentinean politician who said, if you don't want to work, make a committee. Right? Well, this is something similar. So, let's plan from now on what actions we are going to take to change this problem. There are places where they don't have... For example, if I send a doctor to train in the best center in the United States, and he comes and he doesn't have a card, he doesn't have anything, that's the last button. So we have to solve the health problem. It's a purely political problem. Problematic or a purely political health problem. We have to attack from that side as well. Not only... This meeting seemed barbaric to me. But if we stay here, I'm sorry to tell you that, as he said, it's a meeting and we don't want to stay here. That's all. Thank you, Alejandro. Anyone else? Yes. I think it's important to establish a strategy. First, take a picture of the current situation of electrophysiology in Latin America, make a diagnosis, as many have already said, and make an action plan. And I have a proposal. LARS is going to be in Mexico in just five months. We are not going to pretend that we have a solution to the problem, but we are going to create a group in each country, which can be the same people who have been here, work and involve the other electrophysiologists from their respective countries, to know where we are standing. Because there is a very important heterogeneity, which is something we have seen here today. And each country has a very particular situation. And I think we should start there, doing that, and have a preliminary for LARS in Mexico, with the information that can be collected in each country, and from there on, do an activity. Because, as the doctor said, it is a very true example. You can go to the best training site in the United States or Europe, and when you get to your country, you have the same shortcomings, the same problems, well, the truth is that we are not going to do anything. I think that is very important, to have a project to analyze it in a first stage, and to be able to carry it out soon. And Mexico can be an excellent opportunity for a first stage, on the day of what is being done in Cajapar. Please. A short comment regarding a topic that has been touched on several times, and it is to get professionals to train abroad, and the concern that many did is that many of them do not return. I am from Colombia, at that time I was training in electrophysiology in Canada, and it is the question that everyone asks one, and the truth is that I do not know, but the reflection is, what makes those people not return? I mean, why are they not coming back? And I think that much of what has been said here, responds to that question. So, what can we do? And there, let's say that from my personal position, or as an authoritarian group, so to speak, is what to do or what can be done from the societies so that those people go out to train and come back? What can Latin America and societies offer from that point of view? Please. Well, listening to this session, it occurred to me that the sad diagnosis that we have in Latin America, the diagnosis is clear, but what can LARS do to perhaps drive some change? It occurs to me that the presence in the social networks of LARS would be fundamental and focus on countries with more problems. Hiring expert people in the networks, trying to reach health authorities through them, seeking that the population and the authorities understand the benefits in terms of mortality reduction, quality of life improvement with the therapeutic procedures that the members of LARS can offer in each country. I mean, raising awareness through well-managed networks. The industry would finance that perfectly. They are the most interested in increasing the number of procedures or the number of devices. It occurs to me that it could be a principle where LARS could focus on the therapeutic part of this problem that we are seeing today. Thank you very much. Thank you. Well, we were talking in the short coffee breaks with Mauricio de Canavaca, with all the Brazilian and Argentinian friends. One thing that you can start doing at ECHERES is to make it easy for Latinos. To be able to? To make it easy for Latinos, to give them facilities. We quickly began to calculate the cost of coming to this Congress. And for Argentinians, as they said before, it is almost impossible. So, to see how from LARS, as an organism that condenses that part, that concentrates, ECHERES, out there thinking about giving scholarships, of virtual access to the Congress. Because it is no secret that in Latin America there are plenty of trained people, there are plenty of brains, there is a lot of potential. But if we don't promote that potential, we don't give it a push, it doesn't go forward. And it is also known that every time we leave this Congress, all of us who come, we leave with that emotion of wanting to do a lot of things because we start seeing things. Here we see, here is the world's evidence. So, the one who doesn't see it, doesn't have that impulse. That's why it's so important. I wonder, in a measure that ECHERES could take now? It's good, give away so many scholarships for virtual access. What would you do, for example, in Argentina? Would you get together in a hospital room? To see everyone? The Congress. With a single scholarship, everyone would get together. There would be sessions and they would get together. And in that way, we also progress in what is training, in what is the desire to do things. And the rest, you have already said, the political part of health and all that, I think it has to do more with the communication that Latinos have a hard time with. Where I live, particularly in Dominicana, the communication is zero. And if we don't have communication, we don't have statistics that to pressure and generate health policy, we need statistics. As long as we don't have our own statistics, we won't be able to achieve it. What happens if we can't achieve it at the local level? We can have LARS statistics. And those LARS statistics have value in Latin America. So, that was a contribution for ICHERES. Let's see what they tell us. Thank you. Yes, really, I mean, here I have pointed out three, four very, very interesting ideas. But surely there are many more. So, in LARS, as José said, the communication has been quite difficult. Because we are also a very large region. From Mexico to Argentina, it is many kilometers. And each country has its different idiosyncrasies and has its different things. But the idea of this, along with the authorities of ICHERES, is to try to have a rapprochement. That's why at the beginning I said, it's exciting to have electrophysiologists from many countries, to have the support of the authorities of ICHERES, and also to have the people from the industry. Let's not forget that they can be a very important ally, but obviously they have to see the way to have a business, to have a profit, like everyone else. So, that union with the industry is also very important. I would tell you, ideas, I think we have many. Is there any email? We have an email. Social media, I think they are handling it better now. This idea of social media, in particular, I liked it a lot. And we have an institutional email, secretaria.lars, where you can write and be sure that you will always be answered. We now have people dedicated to this, who pass the news to us. We always try to improve communication. It is very difficult. Even when we meet with the Argentines, the Argentine jokes are very different from the Mexicans, and then we don't even understand each other. But, well, we are trying, and this is not a short-term project. It is a medium-term project. Here are the next people, the president, who will be the next in LARS. And, as we talked with Luis, the relationship with ICHERES will be closer every day. It has to be closer. They are also interested in us developing, because that is how they develop things. So, it is very important for us. I don't know if there is any comment. Luis, taking advantage of what you just said, I am curious if there is someone from the companies who would like to comment on what we can do. Let's see if… We can see people over there. Vanessa, you are late. Yes, talking about social media. There is Albert Johnson. We are very, how can I say, very committed. In Albert's team, we have been here for two days discussing how to support Latin America more, how we can help more with training, how we can help more with our technologies, with more affordable costs. We are discussing why it is important for everyone, for patients, for industry, for you. We are looking for it. But the discussion that LARS can help us with is how we can grow with our reimbursement, how doctors can help each other, be together and talk to HMOs to say, I am not going to work on this, I am not going to do a procedure that will only pay me for this. And work for a reimbursement. Another thing that is very complicated for us in the industry, the whole IP business is a very expensive business. Expensive with equipment, expensive with all kinds of systems. And reuse, reprocessing is a very complicated issue for us. Thank you, Vanessa. I think the people from Boston and Microport are not here. They left. You are from Boston. Laura. How are you? Laura from Bayou Solutions. Nice to meet you. I think we have been working on pillars that I think we have common goals. First, training you and the new generations. Access, as you said, I think if we help patients arrive on time and arrive in a more agile way, we are going to win everyone. Because we are going to be able to give them better treatment. And the other thing is how we can also give continuity. There we can work together on data, on data that helps us have better conversations, with data, with evidence for the government. So I think if we work together, we will be stronger. But let's see how maybe in the transitions, maybe of presidency, how we can give that continuity, because this is not resolved in a year or two years. So I think that would be an important pillar. Thank you. I think that to talk to the government, we need data. So the first thing is to create a record, the data. Because we know that if you put the defibrillator with cardiac resynchronization, you have a reduction in mortality. In this morning's slide, I see that 70% of cardiovascular mortality in Latin America, we can increase or reduce mortality. Fibrillation is the same. We have data in the world that is an arrhythmia that has a progression, from paroxysmal to persistent. Precocious ablation will stop the progression. We need to show the data. Without data, no government will do anything. We need data. Probably, if Colombia is separated from Argentina, we don't have enough data. If we put all the data together, it's probably stronger. It's a historical problem of Latin America, of Bolivar. It has to be all together to be able to migrate. Probably for the industry as well. Because in a country as rich as Brazil, richer, with a larger number of procedures, a larger volume of procedures is not necessary. But for Venezuela, Peru, and Chile, it could be that on Monday there is coverage for ablation, on Tuesday and Wednesday there is no coverage for ablation. It's impossible for a mapper to be in Peru all week without a case. That's not possible. But Latin America coverage. It could be that on Monday Venezuela, on Tuesday Cuba. It's the procedure of the day. So the mapper can have the day. It's an idea I have now. But with volume, the cost is lower and the coverage is better. We need that. If you allow me. I'm John Salazar from Medtronic. I'm a Colombian who has lived in the United States for almost 40 years. The difference between the United States and Latin America is not size. Latin American countries have more size when they add territory and even resources. The difference is the lack of unity. And you just said it better than anyone else would have said. You have the power of the world. But to use it, you have to unite and not think of yourself. But think of all those Latin American patients who are not receiving the services that you know should be served. As a union. As a union. Create articles. Things that let all Latin American governments know where the differences are. And I think what Latin America has, Latin America does not want to be the least. It wants to be the best. It always wants to be the best. It has that. It wants to be the best. But to be the best, you have to unify. And let everyone be the best. And let Latin America grow. I think I heard Abel. I heard Boston Scientific. I say it as Medtronic. We want patients to be treated. We want them to have access. But we require the commitment of the unification that you have. And the power that you have. Please. Thank you. Thank you. Well, finally, I would like to give the floor to Néstor. Néstor López Cabanillas. He is currently the secretary of our society. He is one of the main organizers of this event. Again, thank you very much for your participation, for your enthusiasm in this. I think it turned out pretty well. At least I liked it. Well, he will give us some final comments on what is the vision that we have at LARS, of the future, of where we are going in our society. We, together with our sister societies, friends. Well, Néstor, go ahead. Well, thank you. Well, first of all, I want to thank HRS on behalf of LARS, and especially its president, Andrew Cran, Timothy Gregory, Patricia Blake, Luigi, who is next to me, Eduardo, Sat, who is over there, Michelle Anderson. Thanks, Michelle, for all your support. The secretary that HRS gave us helped us a lot. So, I want to thank you for all the help provided for the realization of this event and the excellent willingness to work together in many other activities. I want to thank all the delegates from Latin America who made a huge effort to condense in five minutes information that is very difficult to obtain, and allowed us to appreciate the very different realities of our countries. I also want to thank the entire board of directors of LARS and the ex-presidents. And also, the presence of the majority of the directors of the industry related to Latin America, which shows their interest in understanding us and getting even closer. Six years have already passed since the founding of our LARS society, which was held on May 10, 2017, during an HRS congress in Chicago. Today, we are already a well-constituted and well-positioned society worldwide, with our sisters HRS, IRA and Asian Pacific. But to continue growing, we needed to get to know ourselves even more. And it is only in this event that we show and discuss, as never before, the raw reality of Latin American electrophysiology, in what causes 1. the most frequent diseases and difficulties in their management, 2. the types of health systems, 3. the realities of electrophysiology as a human resource in terms of its number and possibility of training in their country, teaching and working correctly. Analyzing these three pillars, we have to better imagine the future of our specialty and create a program to achieve it. As for the first point, the pillar of diseases, we saw that the most frequent arrhythmia is auricular fibrillation, which cannot be treated in many countries due to the existence or low number of three-dimensional navigators, the lack of trained electrophysiologists, or the loss of the training of those well-trained, as we just talked about, foreigners who, upon returning to their countries, cannot work. It is necessary for local scientific societies to raise awareness of doctors, patients and, as we were talking about, the government, of the importance of adequate management of auricular fibrillation and that companies are encouraged to bring their technology to new markets. On our part, as LARS, we can take care of training courses that can go from the initial step, as Luigi said, of the transeptal function, to take courses on how to do a transeptal function in different countries, up to the workflow of auricular fibrillation. We cannot forget about the disease as ours as the Chagas disease and so related to political, social and educational problems that take to the limit the resources of the health system due to the need for step markers, defibrillators, complex ablations and high-cost medication for the management of heart failure. We must find a way to help to control it. As for point 2, the health system, there is a huge atomization of them in Latin America, ranging from countries where almost everything is paid with cash, to others with very complex systems. But an objective fact is that in many countries, high-cost practices such as implantation of defibrillators, resynchronizers, subcutaneous defibrillators, step markers without cables, left ear closure or ablations with three-dimensional mapping are not covered by the health systems or are partially covered. The solution is complex and depends a lot on the economic situation of the countries and the awareness of governments and insurers. As for point 3, to finish, the reality of the electrophysiologist, the Latin American electrophysiologist, we saw that in several countries there is no arrhythmia society or an entity dependent on the local cardiology society, its creation being important to be able to share knowledge and develop local conferences with the active participation of members of the Latin American society. In many countries there are no local training courses or fellows programs, so it is vital that our society transcends borders and continues to grant training scholarships in North America, as has been done for a long time in Canada, and extends to Europe. And we continue with webinars, distance courses, such as the Master of Cardiac Rhythm, or local theoretical-practical courses, ranging from the advanced course of resynchronizing implants, which we develop in almost all of Latin America, through physiological stimulation, to more complex techniques, such as the epicardial ablation technique. It is important the help of the industry, with the creation of local training centers and the availability of simulators. The absence of a regulation for the exercise of electrophysiology is a reality that must be solved, and will allow to create a Latin American certification exam with real validity. To conclude, I want to emphasize that the economic problems of our region never managed to stop the logarithmic growth of our specialty. That is why the industry must continue to trust. But what can stop us is our own passivity and disunion, as we were just talking about. We must grow together, share our knowledge, because, as the great teacher of Mexican cardiology, Dr. Ignacio Chavez, said, teach as much as you know, that the one who shamelessly keeps his science is at risk of rotting with it. Thank you very much for participating, and thank you HRS for being part of this. Luis, to finish. There is something that HRS can do with the support of the industry dedicated to you, and we have a list of things that I was thinking, from participation to the conference. The registration is very high for Latin America, but maybe we can find a way, a plan with the industry support, and training from transeptal courses to other things. Of course, HRS wants to collaborate, and we are here, but there is also an interest from HRS to have more members, more people as a member of both societies. So we need to find the best way that we can support, so that you feel, I want to be part of the HRS in addition to LHRS, because I'm receiving this from the mother society. We need to figure out at least two or three things that are key to start this collaboration, because, of course, we can speak, but at the end we need to go to something that is practical. I'm a member of the LHRS, I'm a member of HRS, and because of that, I get training, I get something that is practical, that can be touched, because I think this is the most important point that we need to achieve. This was very useful to understand what is the problem. There are more similarities than differences, as we said today. Anyway, thank you so much, and on behalf of the HRS, I would like to thank, of course, Michelle and Tim for supporting us, Marcio, myself, and Nestor, that have been in all the meetings together with Eduardo, as part of the Global Relations Committee, and the current president, Ulisses, and all of you that are in person or connected via Zoom for being part of this summit that was very well attended and supported, and to all the industry people that were here to hear and to try to understand what can we do to improve the patient care, which is what we want. We want to treat more patients and to save more lives. Thank you very much to all for being here.
Video Summary
The video discusses the state of clinical electrophysiology in Latin American countries, highlighting the unique challenges they face and the efforts being made to overcome them. In Bolivia, the most common disease is Chagas disease, and the field of electrophysiology is growing despite limited resources and technology. In Venezuela, El Salvador, Cuba, Argentina, Mexico, Colombia, and Chile, there are challenges such as limited access to advanced technology, training programs, and resources. Each country's healthcare system, including public and private sectors, affects the availability and accessibility of electrophysiology services. The need for increased training, access to technology, and collaboration among healthcare professionals and organizations is emphasized. The Latin America Society of Cardiac Arrhythmias (LARS) recently held a summit to address these challenges. Limited access to healthcare services in remote and rural regions, inequality in access to healthcare, inadequate training programs, and insurance coverage are some of the main challenges discussed. The summit emphasized the importance of collaboration, communication, and improved access to healthcare services, training, and insurance coverage in order to advance the field of electrophysiology and improve patient care in Latin America.
Keywords
clinical electrophysiology
Latin American countries
Chagas disease
Bolivia
limited resources
limited technology
Venezuela
El Salvador
Cuba
Argentina
Mexico
Colombia
Chile
access to advanced technology
training programs
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