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 LARS, 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 LARS is. So 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 Latin America, for being here today either in person or, as we heard, many people are on Zoom. So thank you very much and I give the words to the president of LHRS and to Marcio that actually probably just finished his term. Marcio is the vice president. Yes. He's just finished. 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. Oh, by the way, I'm Marcio Figueiredo from Brazil, LHRS past president. Okay. Good afternoon, 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 work community and strengthen the relationship between regional societies. This event will unite EP experts from Latin America to trigger awareness and face challenges in health, politics, 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. 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. I wanted to say just one thing. I'm sorry for my Sobrek friends because I don't speak Brazilian, but I speak a little Portuguese, but I speak a little Spanish. If you have a question in Spanish, I can understand it and probably give an answer. Thank you for your presence here. If you want, I can translate from Portuguese to Spanish. Yes, probably. Okay, Néstor, thank you. Well, now we'll start with Luis Aguinaga. He's the president of the Argentine Federation of Cardiology. After him, Dr. Jorge Marín, 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 Banina from Uruguay. Another last representative from Dominican Republic, Fernando Vidal. And from Peru, Richard Soto Becerra. I think it's time to start with the video. Thanks. I am Dr. Luis Aguinaga. 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, atrial fibrillation in Argentina. And I would like to present data about our national program, Argentina without atrial fibrillation. The main objectives of our registry were fight against atrial fibrillation. Assistance, focus on detecting new cases. And proper management of sub-treated patients with atrial fibrillation. Educational, patient, physician and community education. And finally, investigation to obtain our own data and sub-studies. We address our problem to the community and the physicians. Also, we include useful information for patients. Information about atrial fibrillation and some manures 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 atrial fibrillation in Argentina was 0.5%. And in our registry, the results were we included more than 9,000 of patients. And more than 1,400 patients didn't have diagnosis of atrial fibrillation previous to the registry. And more than 8,000 have sub-treated atrial fibrillation, mainly due to anticoagulation. And the main risk factors were hypertension, diabetes, hypercholesterolemia, smokers, obesity, heart failure, and pulmonary disease. And regarding to anticoagulation, almost 30% of patients, heart risk patients, were off anticoagulation. And 50% of low risk patients were on anticoagulation, on the contrary. And 12% of heart risk patients were on antithrombosis. And finally, the main socio-economical problems detected were poor patient education, limited access to health systems, unequal access to medicines, mainly anticoagulation, and unequal access to catheter ablation therapy. We think that the first step to solving a problem is to recognize its existence. But we know that in Argentina, we have a big problem regarding to atrial fibrillation specifically. And also, we need to lead different actions to solve this main pandemic problem. Thank you for your attention. Good morning, my name is Jorge Marín, I am a cardiologist-electrophysiologist in Colombia. And we are going to talk a little bit about the epidemiology of heart rhythm diseases in our country. I have no conflict of interest, and I have to emphasize that cardiovascular mortality in our country is a very important cause, the first of all. In 2021, almost 52,000 deaths were registered due to cardiovascular disease, the large percentage of which is ischemic heart disease, followed by cardiovascular disease and hypertensive disease. Unfortunately, we do not have a record of our mortality due to arrhythmia. It is estimated that up to 25% of all ambulatory cardiology consultations are related to arrhythmia, and there is a great increase in the incidence of these. By 2016, according to the WHO, 350,000 Colombians suffered from some type of cardiac arrhythmia, and among them, the most frequent is auricular fibrillation, which represents 50% of arrhythmias in Colombia, with an increase in the presentation in it, with a prevalence that for 2003 was 41% and for 2017 was 87%. With a great economic burden, being in asymptomatic patients with an annual consumption of $2,500 more or less, and in patients complicated with cardiovascular disease due to auricular 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 ventricular heart attack, within which it should be noted the ischemic ventricular heart attack, since daily in our country, for 2019, 100 patients had a myocardial heart attack, and of them up to 20% cause 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 patients who consult for cardiology, excluding auricular fibrillation and auricular flutter. Also, bradycardia occupy a similar percentage, approximately 2%, although we do not have an exact knowledge of the incidence, because we do not have a record of this infection. The strategies involved for the management of these diseases in our country, obviously involve the integral management by cardiology of the care of patients with arrhythmias, and in the year 2022, more or less, 8,000 ablation procedures were carried out, with curative purposes, 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 ablations to 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 registries of the industry that help us in our country, almost 4,000 devices were implanted, and you can see in the distribution how the most common is the unicameral palpation, followed by cardiodesfibrillators, both for primary and secondary prevention of the disease. What challenges do we have at this time in electrophysiology in our country? That is to increase the scope of the specialty of the entire population, since it is covered by our basic health plan. We need to increase the use of databases and strengthen these collaborative databases to improve our knowledge of 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 that has arrhythmias in our country. Thank you very much for your attention. Thank you very much. system in Chile, which is called FONASA. FONASA has full reimbursement for pacing and ablation. So that means that 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 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. So these private companies doesn't give you almost any reimbursement for catheter, equipment, mapping, and ice. So that means that patient has to pay the full price. And also, it means that sometimes you, as an EP, use less equipment or less catheters, for example, less HD mapping, like PENTERAY or HDGRIP, because it's really expensive, and patient has to pay almost the full price. 5% use other health system, 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 are more than 5,000 pacemaker being done in the public system. Around 300 defibrillators and TRTs each. And ablations, they were done almost 700 ablations. But these 700 ablations were concentrated only in three EP centers in Chile. One in Santiago, one in Concepcion, and one in Temuco, where I work. These three hospital has dedicated a EP lab that we only do EP and we doesn't have to share our lab with other specialty like interventionals or vascular. In the private, we don't have a strong data. So we don't know how many procedures are done in Chile, but there is some clinics and private hospital that do plenty of ablation, especially in Santiago, in the capital. We do have numbers from the private companies like Johnson and Johnson and Abbott and Medtronic. So mapping system, we have CARTO and N-site in Chile. N-site is quite new. So last year, 2022, we're done only six cases with N-site. 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. 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 and 35 of them do interventional EP, but we have also really amazing clinician 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 Varas, 2022. As you see in the picture, we are already really happy after a full day of discussing EP clinical cases. And we have some special guests like Karina Hardy here in the middle from Brazil. And the last minute in this talk, we'll be talking about the gaps. So in the public, we need to do more EP. We need more electrophysiologists in Chile. We need more EP labs because most colleagues are really busy doing pacemaker and they doesn'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 eyes. 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. This is because this is a public system patient. In the private, we had 50% of the ablations are atrial fibrillation ablations, and 50% are non-atrial fibrillation ablations. But one important point that I want to bring here, that we have a lot of patients with scar-related VT. Almost 20% of our procedures, 15% to 20% of our procedures are scar-related VT. And most of the procedures, 57% of our procedure of scar-related VT procedures are Chagas disease. So Chagas disease is still a big, important issue, clinical issue in Brazil. And why does this occur? Chagas disease is an infectious disease, and we expected during the years that the number of patients with Chagas has decreased. But what we can see here that we have this reduction, compared in 1990 to 2019. But still, there are some states in Brazil, especially in the Midwest and Northeast of Brazil, the number of deaths related to Chagas is very high, especially Goiás, Bahia, and Minas Gerais. So Chagas, especially on those states, and our center that is in Sao Paulo area, for low risk of Chagas, but we have many referred patients with Chagas, this is a big problem for us. And what's the pathophysiology of Chagas? 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 clearly the benefit of the ICD in patients with Chagas. And we have the Chageski study that is in development, actually they stopped inclusion of patients, they are now using data, and so we have the clear role of the ICD in Chagas disease, especially for primary prevention. But also a big issue in Chagas disease is the ventricular tachycardia. Ventricular tachycardia is very common in patients with Chagas, and most of the ventricular tachycardia are related to the infralateral basal, and Chagas have apical and infralateral basal adherence, and most of the Chagas disease, they have apicardial VT. That's why apicardial ablation was developed in our center by Dr. Mauricio Scaramarca, Dr. Eduardo Sousa, because they had many patients with Chagas and with failed endocardial ablation. So they had the idea using the anesthesiology needle to reach the apicardial, and many patients could be adequately treated using this approach. But what we can see here is there are many patients, it is a proof of this that we can see, this is my thesis, we have many patients with no endocardial scar, and they have a very large apicardial scar. So apicardial ablation is necessary in patients with Chagas. Our current workflow in CORE is if the patient has Chagas disease, we go directly to the apicardial, and if you get VT non-induced and elimination of the substrate, sometimes it's not necessary to go to endo. If the patient still has some VT, or there are some areas related to coronary arteries and phrenic nerve, or mitral isthmus VT, then we go endo. But usually in all patients with Chagas, we go api, and if necessary, go endo. This is Cristiano Dietrich recently published data showing that there's a series of 60, 70 patients with Chagas. If you could eliminate all the late potentials, it was a late potential in sinus rhythm technique, the follow-up was good. But patients who still have late potentials, who still have substrate, they have a very high recurrence rate of ventricular tachycardia. Some other things we must use for treating Chagas, and we are very happy, and we felt that this could be one solution, is the radiotherapy. Radiotherapy, we can have a transmural lesion. We have now eight patients included. This is the first patient we just published this data. And what we can see, that the patients can have VT on the first months, but after this blanking period, that could be four months, most of the patients get no more VT. So this could be promising. One issue, one limitation of the radiotherapy could be the stomach, and it could be the stomach and the bowel. But in this series, we have no problem with this. So this could be promising. To conclude, despite improvements in public health, Chagas disease and Chagas disease VT is still a major problem in Brazil, especially in some states in the Midwest and Northeast. Stratification with cardiac MRI is important, but the role of ICD is not completely known, and Chagas study will bring us some more data. Epiglottis with 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'm Daniel Banina, and I'm going to talk about some epidemiological data about arrhythmias in Uruguay. This story begins in February 1960, when Dr. Orestes Fiandra placed one of the first prototypes of Marcapaso, designed and made by Rum Elqvist at the Karolinska Institute in Sweden. Already in those early days, from the 60s to the 70s, Dr. Fiandra realizes that the main limitation for patients to access and benefit from this technology is the economic one. Therefore, he came 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 of 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, was in the Marcapasos. 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 Marcapasos specifically, these are the statistics of the Fund from 2004 to 2022, where it is clearly seen that there is a gradual increase, accompanying the global trends, the decline of the pandemic and how we recover the pre-pandemic levels. Specifically, in blue we have the Marcapasos 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 Marcapasos is given the Marcapasos without problems. If we make the comparison with the implants per million inhabitants, if we compare with other countries, we choose the European Union because we have many similarities that we will discuss later, but basically Uruguay has 400 implants per million inhabitants, when we should have a much closer figure to Europe of 1,000 implants per million inhabitants. Why did we choose Europe? Well, the evolution of the population pyramid in Uruguay has made us have, in the 1960s, a young pyramid with a very broad base, young people, an old pyramid, an inverted pyramid, decrease in birth and 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 Marcapasos per inhabitant, there is no discrimination in the data provided by the National Resource Fund, neither in the diagnosis nor in the type of device, and we have technological limitations, there have been great technological advances in recent years, but the National Resource Fund has not incorporated the Marcapasos without cables, has not incorporated the remote monitoring, which is only available in a center, has not incorporated all the materials of resynchronization, we are limited, for example, we do not have access to the cell wall through the Fund, and we have limited indications of the stimulation of the left hip and left branch. As for the defibrillators, the situation is much darker, the implants have been increasing over time, in blue we have the implants requested by the doctors, in green the authorized ones, in red the denied ones, the Fund denies 43% of the requests, why does it deny it? Because the Fund has its own regulations that are separate from international and globally accepted scientific evidence, for example, in primary prevention in ischemic 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, and as you can see, as here is the class 2 of the ring, if they have class 1, class 3 or class 4, they are excluded. In ischemic dilated cardiopathy, the situation is worse, because it does not cover any type of indication, never in its entire history has the Fund covered any implant in ischemic dilated cardiopathy. And if we compare the implants per million inhabitants, we see that Uruguay has 60 implants per million inhabitants, compared to Europe, which has 174, that we should be much closer to that figure, to make justice to reality. As for studies and speeches, the history of studies and speeches begins in the 80s, when Dr. Palmira Banzini, who was the mother of electrophysiology in Uruguay, begins the first studies in 1981, after graduating abroad in San Pablo. Dr. Simon Milstein, in 83, goes to Canada and graduates with George Klein, and then settles in Minnesota, and many electrophysiologists went to graduate there, and returned to work in Uruguay, therefore, it is necessary to designate them. He is the mother and father of invasive electrophysiology in Uruguay. Unfortunately, in Uruguay we also have regulatory problems and important in this regard. In 2008, the government established an integral health assistance plan, and there it is established that it is what the providers should give to the patients, but studies and speeches were intentionally excluded. The excuse is always the economic one, which is very expensive, but it should be remembered that the Fund spent the latest available data in step-by-step, it spent 4.5 million dollars, in 2.3 cardiofibrillators, and in other techniques that it has been incorporating recently, ranging from oncological drugs, assisted reproduction, mechanical stroke treatment, TAVI, or all endoprothesis and peripheral interventions, only in oncological drugs it spent 35 million dollars in a year. Despite these regulatory limitations, which have not allowed the development of studies and speeches, there are four teams working in new hospitals, conventional speeches are made, about 500 per year, the most common diagnosis are the anodal re-entry, the accessory veins and the flutter, with successes of 98, 99, 95%, similar to Europe and the United States, which speaks of a highly trained medical population, and with the three-dimensional mapping system very few cases are made, we have an estimated success of 45% in the first procedure, with the recurrence of auricular fibrillation of 25% in 6 months. The big problem in Uruguay apart from the regulatory, are the very heavy tax systems, which makes the supplies count almost 4 or 5 times what they cost in the United States, and it also determines that the equipment is old, we still have some first-generation testing running, we have a couple of second-generation tests, 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 has 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 universal coverage system and highly trained personnel, with comparable results to developed countries. In terms of weaknesses, we have a very hard, very heavy tax system that 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 big 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, the risk factors, the statistics and our main challenges. The Dominican Republic is a country of 48,670 square kilometers with a population of approximately 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 main cause of death is cardiovascular disease, representing 70% of deaths in 2022, according to the National Office of Statistics. As for our risk factors, according to the study published in the ICC 2018, the Dominican population, 31% have arterial hypertension with slight prevalence 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 arrhythmia problem, the Dominican Institute of Cardiology, in a sample of a little over 800 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 general incidence of the population above 65 years of auricular fibrillation is between 8 and 9%, representing approximately 50,000 patients. Stroke is a very important problem in our region and in our country in particular too, with a figure that exceeds 170 annual cases and represents, in this way, the main cause of death in the entire Latin American region and in our country too. Even so, social security does not cover direct anticoagulants for patients, it has a coverage of approximately 200 dollars per year in medicines, and a direct anticoagulant for a month costs 120 dollars. In relation to the statistics or informal data that we have made according to a questionnaire, our main arrhythmia problem is auricular fibrillation, bradycardia and blockages are very common too. Although ventricular tachycardia or ventricular arrhythmias in ischemic cardiopathy are 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, being this greater than 50% in the data presented in Circulation in 2020. The second cardiopathy etiology is valvular, then followed by congenital pathologies. We have 15 electrophysiologists specialists divided into 12 electrophysiology laboratories, 4 of these laboratories have three-dimensional masps approved by FDA. A cryoablation system that presents many problems with the import 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 ablations are carried out, of which 150 to 200 are auricular fibrillations. To graph what happened after the beginning of social security, we have this design, which is the statistics of the Dominican Institute of Cardiology. Since 2007, when social security coverage began, devices were fired, but even today, there is no coverage for high power devices. What are our main challenges in the future? Above all, to promote communication at all levels, between specialists, between specialists and institutions, institutions and public administration, to generate our own statistics, to educate not only the population, but also our colleagues, internal cardiologists, general doctors. After this, and this communication, to generate policies, not only in terms of prevention, in terms of generating greater device coverage, but also in terms of medication. Thank you very much. It is a pleasure to be able to address all of you and to be at the Summit HRS LARCH 2023. My name is Richard Soto de Serra. I am an electrophysiologist at the Instituto Nacional Cardiovascular, INCOR. Today we will talk about the current state of the disorders of the heart rate. 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 Cegarra, who was the first electrophysiologist 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 statistics, 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 records the income of catheters and devices in 2022 in our country. Regarding heart stimulation devices, bicameral markers are the most frequent, a total of 1,782, followed by unicameral strokes in a total of 907. Cardiac Suicide Prevention Devices, such as unicameral defibrillators, reached a total of 92, followed by bicameral strokes in a total of 122. The number of unicameral strokes per million inhabitants in Peru reached 84. If we compare it with Europe, the number of unicameral strokes 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 for Cardiovascular Disease Control, we have data that allows us to identify the diagnoses that led to unicameral strokes. We have identified in the year 2022 that block B was the most frequent diagnosis that led to unicameral strokes, 70%, followed by the Sennheim-Fermo syndrome, 30%. Regarding the DICE implant, the diagnosis or reason was primary prevention, the most frequent, 80%, followed by secondary prevention, 20%. The most frequent diagnosis was hypertrophic myocardiopathy, 52%, followed by ischemic cardiopathy, 17%, and the other cardio... Regarding conventional speeches, the most frequent diagnosis was tachycardia, at the entrance B, 84%, followed by intranodal tachycardia, 16%. Regarding 3D speech, in the year 2022, ear fibrillation was the most frequent diagnosis, reaching 34%. And we have the first 3D speech record in Peru, which was published in the year 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 did not have... Also, a study has been published that evaluates the impact of 3D speech on quality of life in patients with idiopathic ventricular arrhythmias at the National Institute of Muscle Mass in Córdoba. 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. It was a significant increase. 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 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 Malabasi 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. First of all, we would like to thank you for the opportunity to participate in this Latin American Summit 2023. I am Dr. Jorge Luis Arbaiza Simón. I am a cardiologist and electrophysiologist from the city of Quito, Ecuador. We will talk about the data of electrophysiology in our country. First of all, we are talking about a country in which the life expectancy has increased significantly in the last 50 years. We are talking about a life expectancy of 73.7 years, and that means that the older population faces more arrhythmias, mainly what is auricular fibrillation. This is a short summary of how the health system in Ecuador is organized. The health system in Ecuador, as we see, has a total of 630 health establishments, of which there are more of the private service than the public service, and we have a total of hospitalizations, in this case hospitalizations, of around 1 million patients per year. As we can see, although there are more private companies than public ones, the number of hospitalizations is higher. When we wanted to see, with respect to the incidence and prevalence of heart disease, we are facing this situation. We analyzed the first 10 causes of death, as we can see in this graph, and while it is true, both in our country and in others, COVID has represented the main cause of death in 2020-2021, heart disease is in the second cause, but specifically ischemic disease. And if we are going to look for causes of death of heart arrhythmias, we do not find them among the first 10 causes of death. So, specifically, what can we say about Ecuador? A national statistic of incidence and prevalence of heart disease does not exist, unfortunately. A record is being made through the Ecuadorian Society of Cardiology, specifically in the city of Quito we are doing it, with 8 hospitals, both public and private, the largest in the city. And I can give you specifically the hospital in which I work, in which, for example, in the year 2022 we have 235 cases of ear fibrillation, which would represent 3.2% of all diagnoses performed in hospitalized patients. This, of course, is not a number that is representing prevalence or incidence of the disease, but we can have a certain approximation in this regard. What are the requirements in our country to be able to exercise as an electrophysiologist, to have a recognized title as a cardiologist with a specialization in electrophysiology? There is a national entity known as CENESIDA, currently known as ACCESS because they changed the name, which is in charge of recognizing these titles. How many do we have in the country? We have 33 electrophysiologists, they are distributed in the main cities, most of all in Quito, Guayaquil. We have Cuenca, Manta and Loja. These are the 5 cities in which we have specialists in their specialty. Unfortunately, there is no fellow here in the country. All electrophysiologists in the country are trained in other countries. And we can get a statistic, if in the country there are 17.8 million inhabitants, we can say that there is an electrophysiologist for every 540,000 inhabitants. With regard to a gremial association, since 2020, and precisely because of the pandemic, we began to have meetings within the cardiology society to try to organize what are the committees, and specifically the electrophysiology committee was organized with the interesting issue that it had with the specialists of all the cities that we had mentioned. And since then we have been able to organize several national events and three international days, both with the approval of the CIAC and the Latin American Society of Rio. There is no relationship with governmental entities, and in that sense we do not have the support of the government. As for centers and technology available, we have 15 centers in the cities already mentioned. Conventional and three-dimensional mapping systems have been used for some years now. Both radiofrequency energy and cryoablation are used. As novel issues, cardioneuroablation is done in some centers. The intracardiac echo is used as a method to collaborate in the improvement of procedures. And as for devices, we can say that all types of devices are implanted. Step markers with conventional stimulation, with physiological stimulation, cardiodefibrillators, resynchronizers, event recorders. We can say that all kinds of procedures are done in the country. With respect to medical coverage, unfortunately in the public part, there are only two hospitals at the state level and three hospitals at the level of social security to practice electrophysiology, but unfortunately, especially in recent years, we have a lot of problems with materials. There is a lot of lack of materials. As for private clinics making agreements with social or state security, at present, unfortunately, it is almost zero, especially due to lack of payments. And regarding private clinics, there are many private insurances, but unfortunately many of them do not provide material coverage. And we know that materials are the most important thing in the expenses of an electrophysiology procedure. And also in Ecuador, we still have many patients who would be considered as self-financed in private clinics. Unfortunately, and that is why I underline it in big letters, the high cost of materials with respect to countries in the region and unfortunately, it is mostly due to the lack of direct representatives of the companies, has brought us that the costs are very high in the procedures, especially in the three-dimensional mapping, and the high taxes that there are for the importation of equipment also bring us great difficulties. Regarding technology, we have the large companies, with ABOT, more than 20 years in the country, through the national company called CGMED, with them we can count on all the systems that we are mentioning here, also Metronic, approximately 20 years, through Ecuador Overseas. We have the company Boston, through a national company called Equasurgical, and the last one that has entered is Biosense Western, that is, Johnson & Johnson, through a national company called Primus Medical, which has brought the CARTA system. There are small regional representations of what is Biotronic and Medico SPA. If we talk about national health policies, from the State, as we said at the beginning, there is no specific plan by the Ecuadorian Ministry of Public Health regarding the specific and general management of ARRIBAS. And it is being planned, through the Electrophysiology Committee, the conformation, perhaps in the not too distant future, of the Ecuadorian Society of Electrophysiology as an independent entity. Finally, we want to mention some isolated statistics of high-volume centers. In this case, thanks to the help of Dr. José Llorente, we can count on the statistics of two large clinics in Guayaquil, in this case, La Clínica Alcibar, which we can see a total between the year 2020 and 2023 of 786 patients. As we see, a higher load of patients in what is conventional ablation of paroxysmal tachycardia. Secondly, auricular fibrillation and auricular arrhythmias in general. Then, the use of Marcapazo to save arrhythmias, the ablation of ventricular arrhythmias, and finally, ear closure. Another hospital in Guayaquil, in the year 2018-2023, where paroxysmal tachycardia is predominant. And regarding a center in Quito, in which I work, in the Hospital José Andrés de Quito, in the year 2020-2023, 499 patients, of which paroxysmal tachycardia is predominant, in second place, fibrillation and flutter, in third place, ventricular arrhythmias, and finally, Marcapazo normal, as the use of cardiorespirators or resynchronizers. This is all we had about Ecuador. We thank again the opportunity to participate in this event of the World Society of Rhythm, and we want to say goodbye from this country, so mega diverse as Ecuador, with its four regions. Thank you very much. Greetings. I am Federico Malabasi, from Costa Rica. I am going to present the data on the state of electrophysiology in our country. Let's start with the most frequent arrhythmia incidence in our country, which is atrial fibrillation. The population of Costa Rica is 5.2 million, according to the data of the national census carried out in 2022. The incidence of atrial fibrillation is variable according to age groups. Before the age of 55, the incidence of atrial fibrillation was 1 per 1,000 inhabitants. Between 55 and 64 years, the incidence is 5 per 1,000 patients. Between 64 and 84, the incidence doubles to 10 per 1,000, and more than 85 years or more, we already have an incidence of 35 cases per 1,000 inhabitants. As for the second most frequent pathology, regarding electrophysiology, we have supraventricular arrhythmias. They are found in flutters. We have an incidence in two age groups reported according to the census, which is 20 to 55 years, 7 per 1,000 inhabitants, and above 55, 8 per 1,000 inhabitants. In 2022, we have a record of 30 episodes in the National Statistic of Patients with Ventricular Fibrillation and 100 episodes of ventricular tachycardia. It is important to be clear that there may and evidently not be ventricular arrhythmias because many patients have presented as first sudden death and it is not classified as such within ventricular arrhythmias. Subsequently, we have a diagnosis of attention for bradycardia. There are 1,000 cases per year in the National Census. If we look at the production of electrophysiology procedures as a second section, we have a record of 150 national cases of atrial fibrillation, 300 cases of ventricular arrhythmias, 50 cases of ventricular arrhythmias. This includes both ventricular arrhythmias and ventricular extrasystole. We have an implant of 800 devices of the Markapassu type, either unicameral or bicameral, at the national level. We have 60 implants of unicameral defibrillators and finally a national total of 100 implants of cardioresynchronizers. As a second topic of this presentation, I am going to clarify a little about medical care policies at the national level. The country has 9 electrophysiologists. One is a pediatric electrophysiologist and is the only one at the national level. We have 8 electrophysiologists, 5 work at the level of social security, 3 do not exercise as such as electrophysiology, 1 only works in private medicine. From the previous group, it is also important to clarify that only 4 of them perform three-dimensional intervention and speech procedures as such, the others are more dedicated to the diagnostic and implantology part of devices. The requirements for the exercise of electrophysiology at the level of Costa Rica include the incorporation to the professional college, which is the Medical and Surgeon College of Costa Rica. This has some elements that must be completed, whether it is electrophysiology, especially in Costa Rica, requires study abroad. There are no academic training programs in electrophysiology at the level of Costa Rica. All electrophysiologists have studied abroad. So, it requires that cardiology is incorporated. That also requires that cardiology, internal medicine and later electrophysiology be incorporated, a year of social service where the Ministry of Health requests it, and also approve the incorporation exam carried out by three national or international academic partners that the college names. We have as infrastructure at the level of social security, public hospitals, national hospitals for adults. In two of them, electrophysiology is carried out. The center with the highest volume and the one with the highest complexity at the moment is the Calderón Guardia Hospital where three-dimensional speech is done without high and low-energy devices by electrophysiology. The Mexico Hospital alone performs low-energy devices. The San Juan de Dios Hospital performs conventional speech. At the moment, it is not performing and includes ear wax. The other hospitals have the ear wax program within modinami and structural, not within electrophysiology. The Children's Hospital does all kinds of implantology and high-low-energy devices. Public hospitals have all the equipment. There are three-dimensional polygraphs, angiographs. The San Juan de Dios Hospital is not performing and the Children's Hospital does have absolutely all the equipment. There are four private hospitals. They have all the necessary equipment. So, the technology is available both at the public and private level. Financing of the cases at the level of social security is the social security. The electrophysiologists are paid per time, not per case. So, it is a fixed salary regardless of the production they have. At the private level, it is paid in the following way. 70% of the volume comes through policies and reimbursement of medical expenses. 30% are national policies. Direct payment of the patient. 30% of the volume is financed by private banks and commercial houses according to agreements with third parties. Reimbursement. In fact, 20% of the cases are paid by the patient and he takes care of his own reimbursement with his company. 80% of the time, the case must be authorized to be feasible. The average waiting time for reimbursement, both for the doctor and the patient, is 30 days. The origin of the patients, 60 national, 40% are foreigners. The majority of foreigners come from North America. This includes the United States and Canada. 8% are Europeans. 2% are from Central America and the Caribbean. Thank you very much for your participation. Any questions, we are at your service. Thank you. Good afternoon. I am Dr. Roberto Torres Molina, member of the Artificial Stimulation and Arrhythmias Committee, the founder of the Latin American Heart Association and the Bolivian Cardiology Society. Bolivia is a country located in the heart of South America. It has about 12 million inhabitants in a project of the last census carried out in 2012. In recent decades, a rural urbanization has occurred. Currently, 62% of the population lives in the cities. 30 years ago, it was the opposite. This is the population pyramid of Bolivia, where you can see that there is an equality between men and women, but the most striking thing is that 50% of the Bolivian population is less than 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, the governments and the municipalities. Authentic health insurances are selected according to a well-defined population, such as the national cash register, the oil company, roads, banks, universities, etc. Then there are private health insurances that are prepared, public hospitals that treat patients in a second and third level, health centers that are in the first level, and finally health centers. According to this segmentation, for the Bolivian population, 20% are provided in these authentic health insurances, 9.7% in private areas, 61% in public health establishments, 16% in private health establishments, 17% go to a traditional doctor, 40%, that is, almost half, look for home solutions, and 46% ask the pharmacist what he can take for his validity. In Bolivia, the disease with the highest incidence is HIV, with an incidence of 8 to 12% in urban areas and almost 30% in 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, blockages of the ventricles, ear fibrillation, ear alopecia and ventricular arrhythmias. This is more or less the distribution and risk inclusion of how Chaga is distributed in Bolivia, being the red dot 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 auricular tachycardiasis, pulmonary auricular, World Parkinson's Disease, ventricular exorcism and ventricular therapy. The implantation of Marcapax initially was published by his cardiovascular brothers. It is from the year 2000 that, with pioneers such as Dr. Ronald Cuellar and Luis Rangel, the era of electrophysiology of cardiac device implants by electrophysiologists begins, work to which other professionals will be added, all trained abroad. It is in 2019, on the occasion of having organized the first training of electrophysiology and arrhythmias, that the Arrhythmias and Electrophysiology Committee of Bolivia is constituted. In the photo, the founders. To date, there are seven electrophysiology laboratories in the private sphere, distributed in three of the main cities of Bolivia. Three authentic insurance hospitals, a single in-site browser for primary care, all other centers work with polygraphs of 32 or 64 channels. There is no availability of intracardiac ultrasound, there are no training programs of fellows in electrophysiology, and there is only one center that has reported ear fibrillation. Four examples. The implant of cardiac devices 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 surgery and others under evolution. 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, of which almost half of them were in the field of physiological services, and works such as intracardial ultrasound, or ventricular aortic. Aortic fibrillation 54, 4 ventricular fibrillations, 46 ventricular fibrillations, and 45 ventricular fibrillations. And the device implant, 771 devices, of which 154 are single-chamber, 606 double-chamber, 12 bipolar resynchronization therapies, 1 quadripolar, and 8 intracardial ultrasound. Thank you very much. Greetings. Greetings. I will comment on the current state of clinical electrophysiology in Venezuela. Unfortunately, there is no reliable data on the number of cases, both of stimulation and invasive electrophysiology. The volume of implants in recent times has increased gradually. The recovery of electrophysiology has been slow. There has been a significant migration 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% have 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 implants. 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, in their vast anti-radical majority. As for the private sector, the percentage of national level implants depends on the availability of state and private centers. In some states, as I mentioned in the previous slide, private activity represents 100% in general with low volume. There is no regulation that controls who implants the devices, as well as the centers suitable for such. Many private centers in the country implant, several of them less than 10 devices a year. Electrophysiological activity is even more complex. It is still scarce, despite a slight increase in recent years. Probably no more than two 100% state hospitals have the possibility of carrying out invasive electrophysiology. Probably less than 20 cases a year. Some semi-public centers carry out these procedures. You can see in the right slide that practically no state of the most important has the possibility of carrying out talks. In the state of Lara, a semi-public center carries out more than 50 talks a year, with conventional technology, which is an undefined number in private institutions. Activity in private institutions generally tends to depend on mobile devices belonging to certain sectors. In the metropolitan area of Caracas, where there are more than 5 million inhabitants, more than 70 cases are carried out a year, 30-40% using three-dimensional navigation, in this case, Cardo B7 Prime. The Alchaga problem is still valid in Venezuela, with a rebound in recent years. Six million people who 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 and situations are more complex socioeconomically. 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 area of Caracas. In general, few Chagas patients have high-voltage therapies. 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 am going to 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. Within the clinical problems in the area of arrhythmias in the country in frequency order, we have auricular fibrillation with a prevalence of 15% and within this, secondary lethiology is the most frequent. Other supraventricular tachycardia such as rentral-tranodal, accessory vias, atrial flotation, follow them frequently. Subsequently, ventricular arrhythmias related to ischemia, complete ventricular blockages of degenerative theology, most of them, bradycardias. Within the dysautonomy and neurocardiogenic syncope, we have 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-Arbo syndrome and Brugade syndrome. Within the treatment, we carry out speaking procedures when it is possible, either due to the ability to speak or due to the availability of the procedures, the devices when it is possible and in the same way. Within the treatment options available in the country, we have within the 1B group Lidocaine, Fenitoin. Within the 1C group, we have Propafenone. Within the group of beta-blockers, we have more availability, including Metoprolol, Arbedilol, Propranolol, Nebibolol and Visoprolol. Within the group 3, Myodarone. Within the group of blockers of calcium channels, Verapamilo and Diltiazem and other drugs such as Atropine, and Ivabradine. Within the electrophysiological procedures carried out, we have the electrophysiological diagnostic studies, the speaking of supraventricular tachycardia, excluding auricular fibrillation and some ventricular arrhythmias, the device implantation, within this the higher percentage of the step markers and in lower proportion the heart synchronizers. 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 our population, the lack of technology or equipment and the facilities for the realization of these, and in lower proportion the access to devices and some drugs that many times we do not have to give an adequate management. Thank you. First of all, I would like to thank the Latin American Heart Association for the integration that is intended. I am Dr. Elibe Chavez González, Head of the Electrophysiology Session of the National Group and the Cardiology Society of Cuba. Initially, we will present the topic that has been requested, which is related to the clinical presentation of arrhythmias in our country. When an arrhythmia is documented in an electrocardiogram, patients will always be referred to a cardiology specialist, which exists in any province of our country, and they will receive a pharmacological treatment and when they do not resolve with the pharmacological treatment, they are sent to the specialized electrophysiology centers with the objective of making a speech, if it is taxable, or to impose a pharmacological treatment as a strategy of the experience of these centers, which may be superior to the rest of the centers in the country. As for epidemiology and the importance of strategic management of arrhythmias in our country, in the case of supraventricular arrhythmias, we can say that the epidemiological behavior in terms of incidence and prevalence is similar to what is described in international literature. Here are the supraventricular arrhythmias that are presented and here are the forms of treatment that can be applied in each of them in our electrophysiology centers or cardiology centers in Cuba. In the case of ventricular arrhythmias, it is the same to mention that epidemiology is similar to what is described in the literature and also the treatment that is applied is related to what is described in the current treatment guides of cardiac arrhythmias. In our country, approximately 1,100 to 1,200 electrophysiological studies are carried out and about 750 to 800 talks are carried out in the two electrophysiology centers that we have already described that exist and that we are going to show you in another presentation. From the point of view of cardiac devices, it should be mentioned that the largest number of steps are implanted in patients by degenerative ventricular blockage because the fourth part of the Cuban population exceeds the age of 65 years. It is very rare to find infectious diseases such as Chagas and if congenital ventricular blockages can appear with the need for step implantation. Devices such as defibrillators and cardioresynchronizers are also implanted. There are 15 centers of step implantation or there were 15 centers of step implantation 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 Center of the Cardiocenter Ernesto Che Guevara de Santa Clara. When we are going to review the implantation of defibrillators and cardioresynchronizers, observe that the defibrillators are implanted approximately 178 and the cardioresynchronizers are implanted approximately 190 with a rate of 10.7 devices per million inhabitants, which is not similar to the European and developed countries, but we can mention that this rate is very similar to what happens in the countries of our Latin America. The defibrillators are implanted more frequently in patients with ischemic cardiopathy and 28% in patients with dilated non-ischemic cardiopathy and 10% in heart disease. Almost all devices are implanted in patients with less than 35% of ejection fraction and who have already presented a sudden death, therefore, secondary transmission is the first form of implantation of cardiodefibrillators in our country. Here I show you a photo session of our capital, Havana, where the Institute of Cardiology is located and Villa Clara, where the Ernesto Guevara Cardiocenter is located. Thank you very much. Thank you very much. We can start the discussion now. Actually, 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. Number two, the availability of epilabs 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. So, 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. PFA, for example, is supposed to reduce the learning curve and it's probably coming late to LAHRS. Can we do something to make sure that you get PFA soon so that the learning curve to train people can be shortened? What do you think about things like that? Number three, since Chagas is so important, do you have protocols that can be shared from all of you when a patient comes with Chagas? We do A, B, C, and D all the time or everybody is doing whatever they feel appropriate. So, that's something that we can start with each of you comment and then we can ask. I want to invite the panelist, Juan Carlos Serpa and Carlos Duzman from Mexico. Yeah. And Jose Lorente is not here. That's it. Luis Carlos is not coming. Then I invited Luis Aguinaga. Luis Aguinaga, yeah. So, I mean, I already made a provocative question. So, I would like to hear from each of you. Marcio, if you want to start and then Nestor and then all the panelists. Thank you, Luigi. I think that as I saw the presentations, I noticed that there are many things in common and there are many things that are all different. And, obviously, the technology is an issue. But I really don't know how. I think that this kind of forum is important for us to figure out how can we improve technology access to our region. I think this is important. And formation because I noticed that many countries, they don't have possibilities to form physicians. But if I may, I would like to call the attention for a step earlier, let's say. Because I think that we don't have data. I think that we really should have data in our region. It called my attention that some countries like Argentina is trying to do so. There are some other countries that do have data on implants. But there's no let's say formal way of doing. I think this would be a good way to start to make a registry of arrhythmia and centers in our region so we can have this data and we can measure the things we can do from now on. I don't know how HRS or the companies could help us on doing this. I think that the companies are always important because they can help support the cost of something. But if we leave this in their hands, of course they're always going to report the data the way they want. So I think they should be asked to support registries. I think it's important that maybe the whole LHR has come up with a registry. Like we saw in this presentation, it's been very good. How many PR for each country? How many years of training are necessary versus not necessary? And then start to build up a real workflow of things that go there. For example, we know for ablation, PFA will be a hot topic during this conference. If supposed to be the way it looks like, it should reduce the experience of the operator. Of course you need to know how to get access, you need to know how to do transeptal. That part, it's RF or cryo or PFA. You need training for that, no matter what. But once you get there, for sure PFA will reduce the operator experience. So I think this technology should be expedited rather than delayed. Problem is, this new energy comes at a higher cost than the prior one. And the company, I'm talking, they are not even going to want to invest in Europe, because the reimbursement in Europe is not as good as U.S. So they are focusing on investing only in U.S. So I think we cannot practice medicine in a way that you have country A and country C where technology are separated. So we need to create, I think, important rules for the industry in where the technology are available. But before I give the word to you, I mean, I think we should, yes, is it possible you think that HRS can't have every country forming kind of registry? And this registry have to be, first of all, how many procedures are done? Like we saw, everybody collected data, but they have to be in a formal way. And then from there, atrial fibrillation. Then atrial fibrillation, what is deletion set done today in paroxysmal versus persistent in the majority of the Latin American industry? I think there's a lot of data that come in, a lot of scientific opportunity. So I think this is a good way. Now what we can do from U.S. is try to support this registry and try to ask with you to the industry to support the registry and probably receive the data, have somebody from our side that collect this data and review with you. I mean, probably this is a good start. I don't know the opinion of the panel. Luis, I want to break the ice and break the idiomatic frontier of Spanish and English. Maybe if you don't have any problem, turn to Spanish to get more people involved. ¿Puede ser en Español? ¿Así que quiero que participen, que hablen y que comenten su problema. Okay, perfect. Okay, Luis, you understand very well Spanish and Portuguese. No problem. ¿En Español? Sí, sí, sí. Okay. Completamente de acuerdo. Yo creo que la primera cosa que tenemos que hacer para solucionar un problema es primero conocer la magnitude de nuestro problema, ¿no? Y en chagas y en fibrillación auricular y en recursos y en electropsihología 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 las sociedades científicas, ¿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 pocos, hoy hemos venido muy pocos. Hoy 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. Necesitamos, en el año cero, un census. Un census de todo el país, con el número total de electrofisiólogos, el número total del entrenamiento necesario, y mirar para hablar con la sociedad saludable. En América tenemos 7-8% de ablación comparada con 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. No es posible. 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 tienen 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, pues 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. Con 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. Entonces, 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 electrofisiólogos 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, 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 training es la cosa más importante, porque cuando miro al marca paso, el marca paso necesita un training un poquito menos grande. Y tú tienes muchos doctores que pueden implantar el marca paso. La diferencia, el costo del marca paso en Estados Unidos de América es más grande que en América Latina. Pero tú tienes disponibilidad de marca paso. Entonces, 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. Entonces, es un problema que necesita diferentes soluciones. Pero una solución es que más personas necesitan training para hacer el procedimiento. Si no tiene personas para el procedimiento, 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 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? 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, también es importante? Sobre eso tengo un comentario. ¿Puedo hacer un comentario sobre el tema del training? Echarres ahora empezó y ha convocado médicos en Latinoamérica, una iniciativa para hacer las nuevas guías sobre training global con la Sociedad Europea, con Asian Pacific y con Latinoamérica, justamente por ese problema. Creo que empieza, no sé si está Michelle 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, 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, no, yo lo firmo, yo lo suscribo, y esto también es para mi país, esto es para Latinoamérica, esto es para Europa. Viene la guía de training ahora. Perdón. Tenemos un solo minuto, si quiere alguien de la audiencia hacer algún aporte. Gracias. Eliane. Microphone, please. Okay, you can. Hello. I'm from the American Republic. First of all, this is my first time in a meeting like this, in Latin America, and I want to congratulate the organizers, because it's the first time we've met, and everything is different, and I think that after listening to each of the colleagues, we have more similarities than differences. In fact, each one was an echo of the problem that we represent. In those same differences, two aspects caught my attention. One, the costs. We can't be good if we don't have the resources to do it. How are we going to be successful with a ventricular ectopia, with a papillary muscle, if we don't have AIS? It's like throwing ourselves into the blind. So, if we don't work on what are the technological limitations, and the resources, we're not going to be good. And in that same aspect, the limitations that we have in Latin America are our numbers. Our numbers are still low. So, the industries are not going to lower the costs until we have higher numbers. So, if we don't come together as a Latin American region, where all our numbers are shared, and we talk through action policies, or political action committees, that we can do through, united with HRS and LARS, where our numbers are together, after the census that Luigi talked about, those numbers are unity, where we present the industries as our highest numbers, as a Latin American region. So, yes, the costs are going to go down. On the contrary, in an individual way, seeing the numbers that we present, the costs are not going to go down for catheters of contact, or for AIS. We're going to be a few people who pay in private, and most of our patients are not going to benefit. The second aspect is the education aspect. I fully understand why none of the fellows are still training in the country. Again, the numbers. We need a lot of casuistics to be able to have fellows educated in local countries, and we need many years for this. Now, what do we need? In Latin America, we work alone. We don't have nurses trained in our physiology, we don't have trainers, and this is a huge limitation. When many of us and colleagues can do this, when we're going to do complex cases, we have to schedule this mapper to come to our center, from Puerto Rico or Costa Rica, to come to us, which limits our schedule. So, if we don't work hand in hand, one-on-one, all Latin Americans, with the industry, so that our numbers are shared, so that they know that we are strong, and if we share the numbers, the demand will be higher, the costs will be lower, and we will have a better representation at the level of procedures. We don't work alone, and we need mappers, more than anything, before increasing the number of electrophysiologists, we have to work more coherently with what we have. Thank you very much. The last question. Last, and we move on to the break. Yes, thank you. Mauricio Hong, I work in Austin, but I'm from Mexico City. Looking at the numbers, the number of defibrillators that are implanted in Latin America is minimal. So, I think that something that we can do right now is to start stimulating the left branch in markupaseo, which we started doing a year and a half ago, and the fraction of injection is going up. Right now, there are $3,000 less between a bicameral markupaseo compared to a resynchronization markupaseo, 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, which is the lead, $38,000 to $30,000 of Medtronic, which is available to all of you. I think we have to start training all Latin Americans to put left-branch decimation 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, Bill Gates Association, has almost eliminated it, so I do not know if HRS can talk to the Bill Gates Association for the Chagas Association, because it is something that he is interested in, his institution is interested in making this type of contact. So I think if we make an HRS document with Bill Gates, maybe we can have an influence for Emilio Chagas, and good the third, in terms of teaching, I am open, true, being Latino and working in United States, to help in what I can, I have tried to speak to Mexico, Colombia, certain countries, there are limitations also of Latin America, when we offer our help from the United States and these limitations are generally of ego, of arrogance, and I think that, I don't know, you don't want to do that, right? Because I am open for fellows from all Latin America to come to my place, to put Lev Bundle Pacey, we can start the month that comes in, ok? And also to send people to train in the United States, and the problem is that they go back there, right? But well, thank you. We move on to a small break of five minutes, fast, and see you again. Well, first of all, I want to invite the President of HRS, I want to introduce Andrew Clarn, he's the President of HRS, he really was a great support for us, for LARS, and we are so grateful with him and all the effort he has been doing. Andrew, please, you have to... Please, please quieten the crowd. Por favor, los invito a sentarse nuevamente, silencio por favor, va a hablar Andrew Clarn, el Presidente de HRS, que es un honor tenerlo con nosotros. Well, thank you very much, Nestor, it's a real privilege to be here. When I went to Campinas to the LARS meeting, I had several days where it was really such a welcoming environment for the community to welcome the President of HRS and also get to know some people, and I think it speaks to the partnership that we've been working on together as organizations, and I credit Fred, who will make a few comments, Fred Kusumoto at my left here, with the idea of formalizing the process of partnership and creating these summits to try to understand both the organizations but also the process of care and our joint interest in improving the process of access to care and quality of care, and that's through initiatives like not only technology and health systems but education and partnership and communication and joint publications and committee work together and so on. So I think all of these things speak to our common interest in building together, and I'm very grateful also to Nestor for making about a hundred phone calls to people to bring it all together with support from Michelle and Ulysses for his role and leadership of LARS. So 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 would then provide additional care, better care, for all of our patients. Similarly, thinking about pacemaker implantation, which as we were talking about, that's an emergent, 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 Perez Silva from Chile. And Fatima Dumas, president of SOBRAC, the Brazilian Society of Electrophysiology. Please, the videos. I'm going to speak on behalf of Dr. Alejandro Cueto, cardiologist, electrophysiologist, president of the Argentine Society of Cardiology, SADEC. First of all, I want to thank the invitation to the Latin American Society of Cardiac Rhythm, LARS, and HRS, to participate in such an important event at the Latin American level. As for the number of electrophysiologists in our country, in Argentina, there are around 750, based on the data from the last four Argentine electrophysiology conferences. The majority, 72%, are in the city of Buenos Aires and the province of Buenos Aires. What are the official requirements or credentials? Well, they are those that emanate from the resolution of the Ministry of Health, and for this you 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 tin tests, and has also controlled, monitored, and programmed at least 100 step markers, 30 distributors, and 15 re-synthesizers. In addition, he must have at least participated in 100 electrophysiological studies, 50 radio-frequency talks, and have participated in the implantation of 50 step markers, 30 distributors, and 15 re-synthesizers. 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 of the National University of La Plata and grants the title of Specialist in Electrophysiology and Step Markers. It is also done at the University of the Foundation J. Valoro, and the Argentine Society of Cardiology conducts the Higher Course in Cardiac Electrophysiology. As for fellowships, there are many, most of the centers offer these opportunities, and most of them go to Argentina, doctors from their own country, from Bolivia, Ecuador, Colombia and Uruguay. What are the entities that group Argentine electrophysiologists? Well, the Argentine Federation of Cardiology Electrophysiology Council, the Argentine Federation of Cardiology Electrophysiology Council, 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 Federation of Cardiology and the Argentine Federation of Cardiology. And it is one of the largest electrophysiology congresses in Spanish-speaking countries. The last congress, the eleventh congress, which was held last year, in 2022, had 3,160 members, most of them doctors, from 10 countries, and most of them women. What are the scientific activities of the SADEC? Well, the participation in multiple webinars, navigators and intracardiac ecography 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 cardiac ecography, 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 that is 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 workers, and pre-paid medicine. The public health subsystem provides universal and free health coverage in hospitals and assistive institutions, to which every citizen has the right to access, regardless of whether they have other types of coverage, such as social work or pre-paid medicine. Its financing comes from taxes collected at the national, provincial and municipal level. In the public system, there is no defined and homogeneous loan plan for the different hospitals, so the offer 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, the demand is usually higher than the offer, 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 any other type of coverage. It is remarkable that in this system, foreigners are treated, even those who are not naturalized, for free. Social workers. Social workers in Argentina are entities that provide medical care to workers in relation to dependency. They can be state or private, although the vast majority depend on trade unions. Social workers are equivalent to the medical insurance of other nations. By law, all employees in relation to dependency must have medical coverage, and for this reason, the worker and the employer are obliged to pay a percentage of the salary for this purpose. Social security is the main source of non-governmental health coverage in the country. There are almost 29 million people, which is equivalent to 63% of the population. The private system or prepaid medicine. Prepaid medicine companies are private medical institutions for profit, used by a sector of the population that can absorb the cost of a monthly fee. 13.6% of the population enjoys this luxury. As you may have noticed, the percentages exceed the total population, and this happens because there is a superposition of coverage with people who have both provincial and national social security benefits or social and private security, since the different health subsystems are not articulated with each other. I mentioned initially that in the public system there is no defined and homogeneous plan of benefits for the different hospitals and public health establishments. Now, social workers and prepaid medicine companies have the obligation to comply with the benefits established by what in Argentina is called the mandatory medical program or PMO. This contains the set of medical benefits to which all beneficiaries of social security and everything associated with prepaid medicine have the right. That is, it constitutes the set of mandatory medical benefits that, as a minimum floor, must be provided by health insurance agents and prepaid medicine companies. The PMO guarantees to have covered 40% of the cost of ambulatory medicines and 100% of medicines in hospitals and oncological medicines. In conclusion, Argentina has outstanding health virtues, such as inclusive principles through universality with respect to coverage. However, serious flaws are observed in the facts. Today, in many places in the territory, access to health is not guaranteed and when it is, the quality of the service is not homogeneous, since it is determined by the purchasing power. This is because the health system is strongly fragmented, generating a lack of coordination that dilutes the responsibility when it comes to providing coverage. The PMO seeks to grant guarantees of equal coverage for any beneficiary. In practice, social works have differences in issues such as the administrative attention provided, the availability of shifts, the offer of professionals and the closeness of beneficiaries with the centers of care, which generates that there are different qualities of services that, as always, are reflected more intensely in the sectors furthest from urban centers and with lower economic resources. Thank you for your attention. So, the system in 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 jump, 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 of Social Security, which is based on contributions from workers and government contributions. It serves about 70 million people. The ISTE, which is the Institute of Social Security at the Service of Workers, 14 million right-wingers, state workers. The Armed Forces, which is the Army and Navy, 1.5 million. And the Ministry of Health, and now a new system has been incorporated, which is the IMSS Welfare, which is also from the Ministry of Health and serves 40 million right-wingers. Some people have two or three coverages between IMSS or the Armed Forces, ISTE or the Ministry of Health, or even private media or systems. Within the private health system, what do we have? Well, 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 about 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. 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 besides, these medical fees are undervalued. There is no official rector organ in private hospitals throughout the country. Each private hospital is governed by its own individual rules. And besides, the country is very heterogeneous. The population has a different purchasing power. It's not the same in the south, in the north, in the center, and it's not the same in border states either. So the high specialty is generally concentrated in urban centers, but there are states that are important, such as the state of Veracruz, which does not have an electrophysiologist throughout the state. So you have to go outside to do the procedures. As for the public system, the public system has three fundamental problems, which is fragmented and dispersed. There is a brutal administrative bureaucracy and the problem of wages. It is fragmented and dispersed because there are three large health systems, but each state can have its own health system for the workers of that state. So this gets very complex because there can be 10 different health systems and there is no coordination or joint plans between each system. Here we are going to see it. The Health Ministry, which are the largest organizations, have independent directives and do not have mutual collaboration. That is why the Ministry of Health, which should govern the country's rules, does not. The high specialties are also concentrated in a few centers, and there are some centers where electrophysiology is not recognized as such. We have a naming as hemodynamicists, not as electrophysiologists. And there are also few electrophysiologists at the national level, approximately less than 200. And not all electrophysiologists perform the same procedures. The administrative bureaucracy in all of Latin America is brutal. The transfers to the high specialty reference centers are complex. And also the indicators are not based on the quality of 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 for him. The days of bed are not counted. And a patient can be hospitalized for a month, waiting to be bought a pacemaker. Budgets are labeled and individual, they cannot be mixed. We can have supplies for a resynchronising 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, the State Employees' Service. To give you an idea, a month's salary in a public place like the ISTE is equivalent to a private procedure, a passport stamp placement in a private place. So it's very complex because there are places where they don't want to work in the public system, even though there are cardiologists or electrophysiologists, like 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, physiologic stimulation, hysiana, desfilers, simple and complex speech with CARTO system, serofluros, or with the ENCYTE 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 a cardiologist and electrophysiologist from Colombia. The idea is that we are going to talk a little bit about the Colombian health system and what the challenges of electrophysiology are like in Colombia. I have no conflict of interest for this talk, and the idea is that we start by talking a little bit about the Colombian health system. Currently, we have three regimes. One is the contributory, which are those people who have a monthly salary and we give part of our money to contribute to the health system. Another is the subsidized, which are those people without the ability to pay, who, in theory, have the same benefits and the same rights as those who pay for the health system. And there are the special regimes that are part, for example, of the teachers, psychiatrists and the military forces. There are several actors in this. One is the government, which is the one that sets the policies and how the payment will be for each year of the health system. The health care providers, which are basically the insurers who are going to manage the money that the government gives them. The health care providers, which are the clinics and the hospitals that are going to contact those health care providers and the health professionals, who are the ones who are going to end up providing the service. The cost of health in Colombia is relatively high, which is approximately 8% of the gross domestic product, and the expense of the pocket is minimal, with almost universal coverage, with what we call the basic health plan. That basic health plan includes 97% of all available technologies in Colombia for all areas of medicine and 89% of medicines. This, in electrophysiology, translates into the fact that we have the possibility, through that basic health plan, to do medical consultation and device interrogation, to implant any type of device. In addition to that, all electrophysiological procedures, including conventional studies and three-dimensional studies, and it does not cover remote monitoring, which is a felt need that I think we are all having at the moment. At present, we are 64 members already in the Colombian College of Electrophysiology. There are three 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, then two years of cardiology and then two years of electrophysiology. And this applies both if you are trained in the country and if you want to complete an external degree. The completion of an external degree requires that it be a degree given by a university and that these requirements are met in the training program. The vast majority have been trained in Colombia with some people trained in other 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 fluoroscopy, and in procedures with three-dimensional mapping, such as lung tissue isolation, ventricular tachycardia ablation, ventricular atrial extrasystoles or atrial tachycardia. That is to say that the fellows in Colombia train practically all the procedures that we can do today in electrophysiology and they have good training with respect 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 has to be explained 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, and we have to have 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 provision in intermediate cities, and in addition to this, we must start telemedicine programs that allow us to 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 very different geography from the rest of the region, with deserts in the north and very cold climates in the south. And given this particular geography, many of its health policies can be explained. It is important to remember that it occupies the 33rd place of almost 200 countries in better health quality and can be compared with many countries in the Iberian Peninsula. It invests an important part of its gross domestic product in health, one of the highest in the entire region. It is estimated that this investment is around 9 to 10 percent. And it is managed by a national health system called FONASA, which is in charge of compliance, 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 of emergencies. The GES diseases are a set of 87 pathologies that include from pneumonia to different types of cancer, where heart rate alterations are included, bradycardia, tachycardia, all kinds of step-marker implants. And these guarantees, this type of pathology, this law, makes any patient who has any of these diseases is an 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 elsewhere also in the continent, but what it tries is that any patient with a life-threatening disease, regardless of their condition, public or private, or regardless of the level or type of health system they have, the nearest public or private health center must solve the pathology completely. As I said before, all bradyarrhythmic problems, specifically step-marker implants of any type, take place practically throughout the entire geography of the country. This is an important point regarding 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 lead to 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, 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 compromising and innovative country. Public health policies, but the accidental geography, 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 its main 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 Sintra, and I'm the current president of Brazilian Society of Cardiac Arrhythmia. 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 assets. The current structures of Brazil's healthcare system is called Sistema Único de Saúde and were 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 that's 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 implementations of healthcare policies. Nowadays, the private healthcare becomes an important pillar of sustainability of healthcare services in Brazil. It is responsible to serve more than 23% of our population that corresponds to more than 50 million Brazilians. It becomes an alternative for obtaining healthcare services, and it's gained 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 system's performance in Brazil have improved since SU's implementation, but again have not been equal across the population group. Another point that should be highlighted is a great demographic 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 is still some years remain some years below when compared to similar countries. Access to highly complex procedures in Brazil is the main challenger, especially those related to cardiac arrhythmia. According to Brazilian mortality information system, from 2080 to 2019, there were over 350,000 hospitalizations for atrial fibrillation, but only 14% of the hospitalizations but only 14% in ablations procedures for AF performance by SU's. And despite the great reduction observed during pandemic, we currently have about 20,000 space makers implantations and 7,000 electrophysiologist procedures, far below what would be expected. It is also important to address material reprocessing and at this point requires a more comprehensive discussion. In Brazil, reprocessing EP materials is heterogeneously managers across different states in the country. And although federal regulations allows reprocessing, there's a lake of national protocols structured in data that indicates safety of this practice in the country. I hope I have clarified some important points of the Brazilian health care system and thank you very much for your attention. We'll speak from Uruguay, Alejandro Cuesta, last 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. I will briefly explain how the National Integrated Health System in Uruguay works. And then Dr. Manina will speak specifically about the electrophysiological area. Our health system from 15 years ago is integrated, it is at the national level. It is based on four basic principles of sustainability, universality, equality and quality. Sustainability is determined by the government, by the parliament. 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, integrated by the Ministry of Economy, the Ministry of Health, employees' delegates, employees' delegates, employees' delegates and users' delegates. This is the political control of the system administered by the National Health Fund. This National Health Fund is fed by contributions from all workers, from all employers, also from retirees and state contributions. There is also a sub-fund for high-complex and high-cost procedures that we will discuss later. This National Fund is the one that finances full-time 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 performance goals, such as breast screening, colon screening, maternal lactation, etc. This is done through a contract. The National Fund makes a management contract with full-time providers and there it is forced to provide a basket of health benefits and a basket of drugs, which is roughly the vast majority of the benefits, but not all of them, it is the equivalent of our system. It also receives other lower incomes from contributions by tickets, from some quotas from private insurance and from the sale of services. And then there is that smaller fund, with the exception of, as I said, the high-complex procedures, of lower frequency and more expensive, that fund itself establishes what are the mandatory benefits. And here they enter, as they will later tell you, most of the electrophysiology procedures or should enter. The users, then, of the public system, who opt for the public system, do not pay anything at all. Those who opt for, within the integral providers of collective assistance, those pay only tickets. Those who opt for private insurance have to, in addition to repaying the tickets, an over-quota above the capita that the National Health Board gives to the company. And the benefits of the National Resource Fund, for example, a heart transplant, a heart surgery, a defibrillator, for this they do not pay anything and it is universal, it reaches 100% of the population. Everyone has in that framework the same rights and obligations. Then, of the Uruguayan population, 39% opt for, of those integral providers, to attend the public system, because there they do not pay tickets, only 1.8% behind private insurance, because there they have to pay a surplus, and 57% or 60% of the evaporation is obtained in the system of collective companies, which are usually co-governed, in which only tickets are paid and, well, the quality is an intermediate quality among the other two subsystems. And regarding the procedures that are done in the highly specialized system, the user, regardless of where he or she belongs here, the user likes in which image, in which high-complexity center he or she 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 also have doubts, that I am sorry not to be there, but Dr. Manino can probably evacuate. Thank you very much. Good afternoon. I'm Ulyani Mejia, a cardiac electrophysiologist, and I'm following the presentation of my colleague, and I'm going to be talking about the political issues. We have five major problems that we're going to be discussing. Access to health care services, training and education, insurance coverage, integrated societies for electrophysiology, and standardized guidelines and protocols is the last one. Number one and major problem is the access to health services. In our country, approximately 30% of the population in the Latin American and the Caribbean do not have access to health care because of economic reasons. 21% do not seek care because of geographic barriers. In the same token, our country, as many others in Latin America, has advanced economically in the last decade. Along with this increasing 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 other countries, Dominican Republic is right in the middle. We are not at the top or not at the very bottom. But even with this, we're still lacking resources in order to provide appropriate health care for our population, which leads to inequalities and inequities in health care, with a significant percentage of the population at the base of the pyramid. This means that many sections of the population are often at higher risk, as health care problems are often influenced by social factors, such as education, sociocultural level, income, and ethnicity. 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 tech 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 CRDs, 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 limiting the care of this patient, which in terms results in increased multiple procedures or hospitalization because these patients did not have the treatment that they actually needed in the first place. And this, specifically the lack of coverage for high power devices, is important and particularly striking because not even for secondary prevention, ICDs are covered in our country. And the problem is that the financing of health system. Currently, we have a system that finance their health services based on illness, which means that resources have to increase as more people get sick. This mechanism becomes unsustainable because it encourages system based on disease and not health. And for these reasons, over time, the system as well the resources will always be limited. We are working together as an integrated societies in electrophysiology with the creation of protocols and guidelines and appropriateness criteria for diagnostic and therapeutic procedures in EP. We're working to do and we aim for a standardization of all EP labs in our country, creating a unifying force to advocate for our patients. And how we can meet these challenges, we have to integrate three areas, political, social, and economic areas in order to improve the health care in our country. And this is going to be divided in three major areas, primary prevention, secondary prevention and early intervention, and tertiary prevention or response that this is where electrophysiology lands. Thank you so much for your attention. Hi, everybody. Thanks to HRS and 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 Almenara Hospital in Lima, Peru. The beginning was challenging, but the experience was progressively richer. In the following years, new EP cardiologists were beginning to work at different hospitals in the country. At the moment, we have in my country four independent health systems. One of them is a Peruvian Ministry of Health. Another one is a social security health system. Other is a military and police health system. And finally, private health system. For now, we are 24 EP cardiologists for 32 million people in the country. And most of them are working at the capital in Lima, Peru. All EP in Peru were training outside the country. And the EP certificate is going to be approved for the health national authority. We are making all conventional and complex EP procedures using all the tools on the market, including multi-electrode, maping catheter, contact for ablation catheter, and intracardiac echo. We don't have EP society. But extended, but extended, the Peruvian Society of Cardiology has an EP 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. Same for Europeans. And we also have approximately 30% of the population in poverty. Within the basic indicators, the life expectancy at birth is 77 years. And within the main causes of mortality, we have cardiovascular diseases that occupy third place. The demographic transition over the years, we see how it has been decreasing the pediatric population with an increase in the adult and adult population. The main diseases, hypertension, diabetes, overweight, and obesity are highly prevalent in our country. The rules that govern the health sector in Peru, at present, we are based on the political constitution of the year 93, in which it is established that everyone has the right to protection of their health. In 2009, the framework law for universal health insurance was published. And in 2019, the emergency decree that seeks to close the gap of the population without health insurance coverage, seeking to affiliate the population regardless of their socioeconomic condition. The current financing in Peru is intended for total health spending, approximately 5.2% of GDP, well below other Latin American countries. However, this percentage has been increasing both in the public sector and in the private sector. The budget for the health sector is approximately 11.5% compared to the general budget. And cardiovascular diseases are among the main diseases with the highest spending in health services. How is the health system in Peru composed? Its interrector is the Ministry of Health. It is divided into two large groups, the public sector and the private sector. The public sector is made up of the Integral Health System, which is subsidiary and semi-contributive, and Social Security or Health, which is 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 care providers and private insurance companies. It is important to mention that in the public sector, health coverage is total. The coverage at present, we have approximately 78% of the population has some kind of insurance. The vast majority, almost 48%, are affiliated with the Integral Health System and 25% with the Social Security System. Almost 20% of our population does not have any kind of health coverage. The adult population, approximately 89%, has some kind of insurance and almost half of this population is affiliated with 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 concentrate their attention in the two highest quintiles of wealth. Approximately, our health establishments, in the vast majority, are medical centers and health centers, and in a small percentage, they are institutes and hospitals. We have complex hospitals, only 57. What are the main health problems? Lack of staff, lack of competition, there is a poor distribution of specialists, lack of medicines and supplies, many times the teams are underperforming, and lack of protocols. Thank you very much. I would like to thank HRS and LARS for allowing me to participate in this Latin American Summit 2023. We are going to talk about health policies in Venezuela, fundamentally related to cardiac arrhythmias. For all of us, the important social and economic crisis that our country has suffered in recent years is known, which has had a repercussion in the health sector and, consequently, in everything related to the management of cardiac 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 remittances from relatives abroad. We do not have up-to-date and reliable information on cardiovascular mortality and morbidity, and specifically on cardiac arrhythmia in our country. It is important to remember the deep 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 issue we are touching on, that 30% of well-trained and qualified electrophysiologists who had a professional life in our country have also been part of this group of emigrants. All this is related, of course, to the deep 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. So I think it is important to take a picture of what it was in 2015. We had 12 three-dimensional navigators. Public employees at that time had a wide range of insurance policies provided by the state, mainly providing coverage for electrophysiology procedures and high-cost device implants, and another percentage of the population had insurance that allowed their coverage to access these therapies. Currently, there are only two CARTO 3 navigators 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 aid 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 defibrillators and resynchronizers is increasing. The supply of antiarrhythmic drugs is much more limited than it was years ago, and only two centers, exclusively public, carry out ablations in the private and mixed sectors. More than 20 institutions carry out invasive electrophysiological procedures. So we can conclude that in Venezuela there is currently no reliable and updated information on the mortality and morbidity of arrhythmic disorders that allows strategies to attack these pathologies. The available data comes from the opinions of a group of experts and some fundamentally public institutions, as well as the extrapolation of bulletins issued in previous years. These shortcomings constitute a barrier for strategies to solve these problems, and the Venezuelan state must give priority to the budget of the health system, and the Ministry of Health must provide reliable and up-to-date epidemiological information so that together with non-governmental entities and scientific societies we can implement actions to optimize the care of the population. Thank you very much. Hello, I greet you, Marta Reyes, electrophysiologist of El Salvador. Thank you for the invitation to this Latin American symposium. I am going to talk a little about the health system in El Salvador. We have only three qualified electrophysiologists, that is, our attestations 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 Association of Cardiology 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 study of conventional electrophysiological diagnoses and speeches, we have a three-dimensional navigation system, and an intracardiac echo. The health system is distributed in three sectors, within which 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 to. We have those patients who have a private insurance, either with national or international coverage. The payment will depend on the copay that each of its policies contemplates. And we have these patients who cancel 100% of the consultation and procedures, who do not have any kind of private insurance. In this sector, most electrophysiological 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 served. The payment that each of them makes is according to the quota that is monthly discounted from their salary and has coverage for medicines and some procedures. In social security, electrophysiological studies and discussions were carried out for several years, but at this time they are not being carried out due to equipment damage. Inside the devices, steps are mainly implanted and very few defibrillators. This is the sector that is working on a project for the acquisition of a three-dimensional navigator. In the public system, the largest percentage of the population is served. However, there is no coverage for the implementation of electrophysiological studies and inside the devices, only steps can be implanted. Thank you very much. I would like to thank the Latin American Summit 2023 of the Cardiac Rhythm for the opportunity. Now we are going to present the topic B1 related to health problems and health policies. To be approved in our work as electrophysiologists, at least one of the specialists in the centers that exist in our country has been trained abroad. One of them in Buenos Aires and another in Madrid, Spain. From a theoretical and practical point of view, we have received support from Dr. Luis Barja, who has received the sponsorship from Abbott and Biotronic, and has come to our country since 2015, for 15 days, twice a year, to Havana and the city of Santa Clara to train the groups of electrophysiologists in these two provinces. We have also received support from doctors from Brazil, the United States, as well as technicians from El Ensaite, from Colombia. The qualification of the rest of the professionals is from courses of diplomas approved by the corresponding universities of Havana and Villa Clara. A course that lasts a year and graduates with a diploma certification. There are no university degrees in our country. Once these diplomats have graduated, they continue their work in centers where there are also professors who already have experience in the implantation of step marks or electrophysiology in the other centers of our territory. As for the implantation of heart devices, the devices are implanted in 13 provinces of the national territory, and in three of them, marked in red, which is the province of Havana, Villa Clara and Holguin, heart defibrillators and resynchronizers are also implanted, where qualified staff exists for this task. In the 13 provinces of the country that have implantation centers, there are a total of 19 implantation centers, 5 in Havana, 2 in Villa Clara and 2 in the province of Seville. The rest of the provinces have a per capita center. Here I show you a work that we have published in 2008 in the magazine Archivos de Cardiología de México, where it is shown that we have been working on stimulation in alternative sites, such as the septal region, to avoid cardiac dyssynchrony. In our country, we have developed this technique without having the necessary tools. We have two electrophysiology centers in Cuba, one in the Institute of Cardiology in Havana, and one in the Ernesto Guevara Cardiocenter in the province of Santa Clara. In the Institute of Cardiology in Havana, we have developed this technique without having the necessary tools, In the Institute of Cardiology in Havana, we have an Enzyme Velocity and a Radiofrequency Cubic. These are the arrhythmias to which we give the ablative treatment, but we must mention that at the moment the Enzyme Velocity is not working for the reasons that we show here, and the Radiofrequency Cubic is working. We do not have Intracardiac Echocardiography in the country. In the Villaclara Cardiocenter, we also have a Radiofrequency Cubic, and this type of arrhythmias is being worked on and performed. 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, here in the region of the tip of the right ventricle, and finally, this one that we show here, the ablation of a fascicular-idiopathic ventricular tachycardia posterior to the left ventricle. The Cuban Society of Cardiology organizes scientific activities at the Institute of Cardiology, generally once a year, and also at the Cardiology Congresses, two of which are organized in the country, one of national character and one of international character, which increases the knowledge of electrophysiology in the cardiology and electrophysiology specialists of our country. And here I show you a panoramic view of Varadero Beach 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 the health systems in the different countries. There are places where most of the health is done in a private way, paying in cash. We saw 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 be able to understand us. So, I don't know, people from Brazil, what do you think? Mexico, what are you thinking? How can we, as LARS, help with this? I don't think so, but what do you think? Well, I will speak in Portuguese, so that you can understand me. I think it is a very complex problem. We have a common denominator in all of Latin America, which is, everyone talks about problems with infrastructure, training, equipment, industry, costs. We all have the same problems in different intensities. And I was here listening to the lectures and thinking, it is as if it were a critically ill patient. They don't have just one problem, they have multiple problems, a failure of multiple organs, and they need an integrated approach. It is no use saying that we are going to put in Cuba more than 200 electrophysiologists who will not solve the problem. We have to have an integrated governmental action that listens to doctors, specialists, who want to invest in health, who are broken governments, all with financial problems. So, I don't have the solution to all the problems, but I think the message that remains for me, listening to everything I heard today, is that we need to have an integrated action. And LARS can be this link for integration between several countries, that we can pressure the governmental actions with the support of HRS, with the support of scientists, so that we can pressure the governments and also pressure the help of the industry, which can also help us to gradually try to improve our numbers, which are really very, very low compared to the rest of the developed world. Yes, I would like to comment that, well, we all know that our governments are not the ideal, it is a necessary evil that we have, but finally we need them. At some point we have to interact with the governments and we have no choice. Some worse, some better in Latin America, but there they are. Here the question for Ana, for José, for Marcio, for all of you, is to try, and that is the objective of this, to try to see how we can help, how we can organize ourselves through society, through LARS, with the help of HRS, which, as you can see, now we are trying to join efforts in many things. So the question is, how do you see, what do you think we need and what can we do as a medical society, to be able to develop and advance a little faster in the development of our activity throughout Latin America? Well, I think that 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, to reuse materials, catheters, devices have also been reused, donated, from people who die. And here we have scientific evidence that this is a practice that is ultimately not harmful to our patients. And I think that through LARS and our societies, what we can do is give this endorsement, this scientific support to these practices, which, well, are not entirely orthodox, but which do not harm our population either, and that, well, in a way, we are a little bit 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 registries, censuses, I think it is also important to publish these experiences that will probably extend 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 there are, as you mentioned, that in different countries there are different realities. So, I think that, for example, in countries… I want to take advantage of the opportunity that HRS is giving us with this summit. For example, in countries that have difficulty in 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 be used to incorporate technology. I have no idea how it can be done. But yes, to be a bridge for training, for people, that's for sure. That could be done with the help of society. Society should also listen to its partners. I think that we should always be open or always ask how we are doing now. What are the needs? And maybe help someone who needs it with someone who can give. For example, with training. But I also think that it is very important to register, to have statistics of procedures, of centers, of devices, because that is very important. I think that maybe with the help of HRS and with the support of the industry, because that has a cost. I know that it can be done in other ways, but anyway, that has a cost. So I think that is also very important as a plan for the future. Here in the panel is José Moltedo, who is a privilege for us in Argentina to have a pediatric electrophysiologist trained abroad. And I think that such an important sector of young people does not have the backup, the support of electrophysiology that Latin America should have. I don't know, José, what could you say? Thank you for the young man. I'm not that much. No, actually, I, listening to the problem that we have in the region, I would like to make a self-critical statement, if you will, of the ARS society. I think that we should all, as a community, look for a more effective way to get there. I think there is a bit of disconnection between what society does and reality in the different countries. And I think it is related to problems in the internal communication and in how we communicate. I heard at the end of the first session about the need to make a diagnosis of the situation or status of electrophysiology in Latin America, to be able to know the nature of the problem and, from there, articulate potential plans to solve the problem. And, well, we, from the Pediatric Committee, two years ago published in scientific journals the current state of pediatric electrophysiology. And I don't know if that was communicated in the way it should have been communicated and if it was given the value it should have been given. And I belong to the society and I am in the Electrophysiology Committee. And I feel that sometimes the arrival is not the most effective. This type of event may be useful, but it is also true that we are few, or relatively few, the Latin American doctors who come. So, I think that, from the ARS, we should consider how we can get there better, communicate better, open up more the functioning and the decisions that are taken to be able to address the problem in a more efficient way. Any questions from the public? A comment? Alejandro? Alejandro? There is a health policy. So, we have to attack from that side too. If we don't have a meeting, there was an Argentinean politician who said, if you don't want to work, make a committee. Right? Well, this is something similar. So, let's plan from now on what actions we are going to take to change this problem. There are places where they don't have, for example, if I send a doctor to be trained in the best center in the United States, and he comes, and he doesn't have a card, he doesn't have anything, it's the last button. So, we have to solve the health problem, which is a purely political problem, a problematic problem, or a purely political health problem. We have to attack from that side too. Not only... This meeting was amazing, but if we stay here, I'm sorry to tell you that, as he said, self-criticism is a meeting, and we stay here. That's all. Thank you, Alejandro. Anyone else? Yes. Yes, I think it's important to establish a strategy. First, make a photograph of the current situation of electrophysiology in Latin America, a diagnosis, as many have already said, and make an action plan. And I have a proposal. LARS will be in Mexico, in just five months, and we're not going to pretend that we have a solution to the problem, but we will create, in each country, a group, 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, of the information that can be collected in each country, so that from then on, we can do an activity. Because, as the doctor said, it's a very true example. You can go to the best training site in the United States and Europe, and when you get to your country, you have the same deficiencies, the same problems, well, the truth is that we're not going to do anything. I think that's 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 start on the day of what is being done in each country. Please. A short comment regarding a topic that has been touched on several times, and that is, to get professionals to train abroad, and the question that many were asking is, many of them don't come back. I'm from Colombia, at that time I was training in electrophysiology in Canada, and it's the question that everyone asks, and the truth is, I don't know, but the reflection is, what makes those people not come back? I mean, why aren't they coming back? And I think that a lot of what has been said here answers that question. So, what can we do, and let's say that from my personal position, or as a group, is, what can be done from the societies so that those people can go out to train and come back? What can Latin America and the 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. To hire expert people in the networks, to try to reach health authorities through them, to seek that the population and the authorities understand the benefits in terms of mortality reduction, improvement of quality of life with the therapeutic procedures that the members of LARS can offer in each country. That is, to raise awareness in the networks, well managed. The industry would finance that perfectly. They are the most interested in increasing the number of procedures or the number of devices. It occurs to me that it could be a principle where LARS could focus on the therapeutic part of this problem that we are seeing today. Thank you very much. Well, we were talking in the short coffee breaks with Mauricio Escanavaca, with all our friends from Brazil and Argentina. One thing that Eicheres can start doing is to make it easy for Latinos, to make it easy for Latinos, to give them facilities. We quickly began to calculate the cost of coming to this Congress and for Argentines, and they already said it before, it is almost impossible. So, to see how from LARS, you can, as an organism that condenses that part, that concentrates, Eicheres out there thinking about giving scholarships for virtual access to Congress. Because it is no secret that in Latin America there are plenty of trained people, there are plenty of brains, there is a lot of potential, but if we do not promote that potential, we do not give it a little push, it does not go forward. 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 begin to see things. Here we see, here the world's evidence is presented. So, the one who does not see it, does not have that impulse. That is why it is so important, and I wonder, in a measure that Eicheres could take now, it is good, give so many scholarships for virtual access. What would they do, for example, in Argentina? They would meet in a hospital, in a hospital, to see everyone, the Congress. With a single scholarship, they would all meet, they would have sessions and they would meet. And in that way, we also progress in what is training, in what is the desire to do things, and the rest, they have already said it, the political part of health and all that, I think it has to do more with communication, because the communication that Latinos have is very difficult. Where I live, particularly in the Dominican Republic, the communication is zero, and if we do not have communication, we do not have statistics, that to pressure and generate health policies, we need statistics. As long as we do not have our own statistics, we will not be able to achieve it. What happens if we cannot achieve it at the local level? We can have large statistics, and those large statistics have value in Latin America. So that was a contribution for Echeres. What do you say? Yes, really, I have pointed out three or four very, very interesting ideas, but surely there are many more. So in large, as José said, it has been quite difficult communication, because we are also a very large region, from Mexico to Argentina, there are many kilometers, and each country has its different idiosyncrasies and has its different things. But the idea of ​​this, along with the authorities of Echeres, is to try to have an approach. That is why at the beginning I said, it is exciting to have electro-biologists from many countries, to have the support of the authorities of Echeres, and also to have the people of 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. There is an email, the social networks, I think they are now being handled better. This idea of ​​social networks, in particular, I liked it a lot. And we have an institutional email, secretaria.arroba.lars, where you can write and be sure that you will always be answered. We now have people already dedicated to this, who pass the news to us, and there is always a… we try to improve communication, it is very difficult, it is very difficult, even when we meet with the Argentines, the Argentine jokes are very different from the Mexicans, and then we don't even understand each other. But hey, we are trying, and this is not a short-term project, it is a medium-term project. Here are the people, the president, who will be the next in LARS. And, as we said, as we spoke with Luis, the relationship with social networks will be closer every day. It has to be closer. They also obviously have an interest in what we develop, because this way they also develop things. So, it is very important for us. I don't know if there is any comment. Luis, taking advantage of what you just said, I am curious if there is someone from the companies who would like to comment on something, on what we can do. Let's see if… We see people over there. Vanessa, you are from Abbott. Yes, speaking of social networks. We are Abbott, yes, Johnson. We are very, how can I say, very committed. We are in the Abbott 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 accessible costs. We are discussing why it is important for everyone, for patients, for the industry, for you. We are looking for it. But the discussion that LARS can help us, how we can grow with our reimbursement, how doctors can help each other, be together and talk to HMOs to say, this is not going to work, I am not going to do a procedure that is going to pay me just this, and work for a reimbursement. And another thing that we are, that is very complicated for us in the industry, the whole IP business is a very expensive business. Expensive with teams, expensive with all kinds of systems. And reuse, reprocessing is a very complicated issue for us. Thank you, Vanessa. Thank you. I think people from Boston and Microport are not here, right? No. They left, right? You are from? Ah, yes, from Boston. Do you want to say something? Laura. How are you? Laura from Biosystems. Nice to meet you. I think we have been working on pillars that I think we have common goals, right? First, training you and the new generations. Access, as you said, I think if we help patients arrive on time and arrive in a more agile way, we are going to win everyone, right? Because we are going to be able to give them better treatment. And the other thing is how we can also give continuity. There we can work together on data, right? On data that helps us have better conversations with data, with evidence for the government, right? So, I think if we work together, we are going to be stronger. But let's see how maybe in the transitions, maybe in the presidency, how we can give that continuity because this is not resolved in a year or two years, right? So, I think that would be an important pillar. Thank you. I think that to talk to the government, we need data. So, the first thing is to create a record, the data, because we know that if you put the marker of the fibrillator with cardiac resynchronization, you have a reduction in mortality. In this morning's slide, I see that 70% of cardiovascular mortality in the Latin American country. So, we can increase or reduce mortality. Fibrillation is the same. We have data in the world because it is an arrhythmia that has a progression from paroxysmal to persistent. So, the early ablation will stop the progression. So, we need to show the data. Without data, the government will not 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 will probably be stronger. It is a historical problem of Latin America, of Bolivar, which has to be all together to be able to emigrate. Probably for the industry as well, because in a country as rich as Brazil, no, richer, which has a larger number of procedures, which has a larger volume of procedures, it is not necessary. But for Venezuela, Peru, and Chile, it is possible that on Monday there is coverage for ablation, on Tuesday and Wednesday there is no coverage for ablation. It is impossible for a mapper to be in Peru all week without a case. That is not possible. But Latin America has coverage. It is possible that on Monday in Venezuela, on Tuesday in Cuba. This is the procedure of the day. You can have the mapper on the day. It is an idea that I have now, but with the volume, the cost is lowered and the coverage is better. We need that. If you allow me. I am John Salazar, from Medtronic. I am a Colombian who has lived in the United States for almost 40 years. The difference between the United States and Latin America is not size. 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 serve. As a union, as a union, create articles, things that let them know, all Latin American governments, where are the differences. And I think that 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 has that desire 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, and 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. 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 about the vision we have in LARS, the future, where we are going in our society, us, together with our sister societies, our friends. Well, Néstor, go ahead. Thank you. Well, first of all, I would like 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 you provided for this event, and the excellent willingness to work together in many other activities. I want to thank all the delegates from Latin America who made a huge effort to condense in five minutes very difficult information to obtain, and allowed us to appreciate the very different realities of our countries. Also, to the entire HRS board of directors, and to the former presidents. And also, the presence of most of the directors of the industry related to Latin America, which shows their interest in understanding us and getting even closer. Six years have passed since the founding assembly of our LARS society, which was organized on May 10, 2017, during an HRS congress in Chicago. Today, we are a well-established and well-positioned society worldwide, with our sisters HRS, IRA and Asian Pacific. But to continue growing, we needed to get to know ourselves even more. And it is only in this event that we show and discuss, as never before, the raw reality of Latin American electrophysiology. What it does to 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, possibility of training in your country, teaching and working correctly. Analyzing these three pillars, we have to better imagine the future of our specialty and create a program to achieve it. As for the first point, the pillar of diseases, we saw that the most frequent arrhythmia is the auricular fibrillation, which cannot be treated in many countries due to the existence or low number of three-dimensional navigators, the lack of trained electrophysiologists or the loss of training of those well-trained, as we just talked about, abroad, who, when returning to their countries, cannot work. It is necessary for local scientific societies to raise awareness of doctors, physicians, patients and, as we were talking about, the government, of the importance of adequate management of the auricular fibrillation and that companies are encouraged to bring their technology to new markets. For our part, as LARS, we can take care of training courses that can go from the initial step, as Luigi said, of the transeptal function, to take courses on how to do a transeptal function in the different countries, to reach the workflow in auricular fibrillation. We cannot forget about the disease as ours as 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 cardiac insufficiency. We must find a way to help to control it. Regarding the second point, the health system, there is a huge atomization of it in Latin America, going from countries where almost everything is paid with cash to others with very complex systems. But an objective fact is that in many countries, the high-cost practices such as implantation of defibrillators, resynchronizers, subcutaneous defibrillators, cable-free step-markers, left ear plug closure or ablations with three-dimensional mapping are not covered by the health systems or they do it partially. The solution is complex and depends a lot on the economic situation of the countries and the awareness of the governments and insurers. Regarding the third point, to finish, the reality of the electrophysiologist, of the Latin American medical electrophysiologist, we saw that in several countries there is no arrhythmia society as a dependent entity of the local cardiology society, its creation being important to be able to share knowledge and develop local conferences with the active participation of members of the Latin American society. In many countries, there are no local training courses or fellows programs, so it is vital that our society transcends borders and continues to grant training scholarships in North America, as has been done for a long time in Canada, and extends to Europe. We continue with webinars, courses at a distance, such as the Master of Cardiac Rhythm, or theoretical-practical courses that go from the advanced course of implantation of resynchronizers that we develop in almost all of Latin America, through physiological stimulation, and reaching more complex techniques, such as, for example, the epicardial abrasion technique. It is important the help of the industry for 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 master of Mexican cardiology said, Dr. Ignacio Chavez, they teach as much as they know that the one who brazenly 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. Before the last word, the conclusive word, something that also, I'll say this in English, that you need to figure it out as a Latin American is how practically we can help you. And we need, of course, it's economic problems, so we need the support of the industry. But 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 transept courses to other things. So, of course, HRS wants to collaborate and we are here and we want, but there is also an interest from HRS to have more members, more people as a member of both societies. So we need to find the best way that we can support so that you feel, oh, I want to be part of the HRS in addition to LHRS, because I'm receiving this from the mother society. And we need to figure it 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's 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. 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 Ulysses and all of you that are in person or connected via Zoom for being part of this summit that was very well attended and supported 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.

clinical arrhythmias

healthcare systems

Latin American countries

Venezuela

El Salvador

Cuba

Argentina

Mexico

Colombia

Chile

limited access

specialized care

resource constraints

lack of training programs

disparities in healthcare access