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Case Report | DOI: https://doi.org/10.31579/2690-1897/261
*Corresponding Author: Ramachandran Muthiah, Morning star Hospital, Enayam Thoppu, Kanyakumari District, India.
Citation: Ramachandran Muthiah, (2025), Kissing Vegetation on Aortic Valve, J, Surgical Case Reports and Images, 8(6); DOI:10.31579/2690-1897/261
Copyright: © 2025, Ramachandran Muthiah. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 09 June 2025 | Accepted: 17 June 2025 | Published: 25 June 2025
Keywords: bicuspid aortic valve; infective endocarditis; kissing vegetations; acute aortic regurgitation; aortic valve replacement
A 17-year-old female was admitted with features of heart failure and a febrile illness. Blood cultures were negative and ECG revealed normal. Echocardiography revealed a ‘ kissing- type’ of vegetation on the bicuspid aortic valve with severe aortic regurgitation and a dilated left ventricle with moderate dysfunction. The management of aortic insufficiency occurring in infective endocarditis may differ and the presence of intractable pulmonary edema or shock is a clear indication for prompt valve replacement. The traditional diagnostic criteria are insufficient to diagnose infective endocarditis and the modified Duke criteria provide high sensitivity and specificity over 80% for the diagnosis of native valve endocarditis with positive blood cultures.
Infective endocarditis is a microbial infection of a heart valve (native or prosthetic) or the mural endocardium, leading to tissue destruction and formation of vegetation. Its incidence varies from 1.7- 7.2 cases / one lakh persons-year and the female to male ratio was 1:2 [1]. There are substantial changes in the epidemiology profile over the last few decades [2] as median age group has increased from 30 – 40 to 47-69 years and rheumatic heart disease is no longer the main risk factor in Western countries. The most common predisposing lesion for aortic valve endocarditis is congenitally bicuspid aortic valve (BCAV). Inadequate production of fibrillin-1 during valvulogenesis may disrupt the formation of aortic cusps, resulting in a bicuspid aortic valve and a weakened aortic root [3], which may complicate infective endocarditis in 9.5 % of cases [4]. Isolated Aortic regurgitation was found in only one-twenteeth of a large series of patients in India, 2.7% of patients under 19 years in Brazil as a unique valvular dysfunction. The usual natural history is a long asymptomatic period in which mild-to-moderate regurgitation is well tolerated during the compensated phase and in adults, a rate of < 6>
A 17-year-old female was brought to the emergency room with a history of sudden onset of breathlessness. Her pulse rate was 87 bpm and blood pressure 110/60 mmHg. She had a history of rheumatic fever during childhood, an episode of febrile illness for 10 days and taken antibiotic treatment recently. Blood chemistry revealed normal and blood cultures were negative. ECG revealed normal as shown in Figure 1 and X-ray chest revealed dilated LV (left ventricle) as in Figure 2. Physical examination revealed grade 3/6 early diastolic murmur over left mid sternal border, basal crackles over lung fields and no peripheral signs of wide pulse pressure. Transthoracic echocardiography revealed vegetations on anterior and posterior leaflets of aortic valve as in Figure 3 and Figure 4, with a “kissing-type “as in Figures 5, 6 and 8. The aortic valve was bicuspid with an attached vegetation as in Figure 9 and it was severely regurgitant as in Figure 10 and Figure 11. The left ventricle is dilated as in Figure 12 with moderate LV dysfunction as in Figure 13. The thoracic aorta was prominent as in Figure 14 with a ‘holodiastolic flow reversal’ as in Figure 15. The patient was treated with digoxin (0.25 mg, half daily), diuretics (Injection. Furosemide 20 mg IV twice daily), ACE inhibitors (tablet. Enalapril 2.5 mg twice daily) along with 2 weeks course of intravenous (IV) cefotaxime (1g) and amickacin (500mg) twice daily and advised aortic valve replacement at the earliest with lifelong penicillin prophylaxis and continuation of antibiotics for 6 weeks since the vegetations remain stable after 2 weeks of treatment, but without any embolic episodes.
Figure 1: Showing the normal ECG in acute severe aortic regurgitation in a 17-year-old female
Figure 2: X-ray chest PA (postero-anterior) view showing the dilated left ventricle due to acute severe aortic regurgitation [6] in a 17-year old female.
Figure 3: Parasternal long axis view showing the vegetation on the anterior leaflet of aortic valve (arrows) in a 17-year old female.
Figure 4: Parasternal long axis view showing the vegetation on the posterior leaflet of aortic valve (arrow) in a 17-year old female. AV-aortic valve.
Figure 5: Parasternal long axis view showing the “ kissing-type” of vegetations (arrow) on the aortic valve in a 17-year old female.
Figure 6: Parasternal long axis view showing the “ kissing-type” of vegetations (arrows) on the aortic valve in a 17-year old female- large view.
Figure 7: Apical view showing the vegetation on the aortic valve (arrow) in a 17-year old female.
Figure 8: Apical view showing the “ kissing-type” of vegetations (arrow) on the aortic valve in a 17-year old female.
Figure 9: Short axis view showing the bicuspid aortic valve with vegetation (arrow) in a 17-year old female. AO-aorta, BCAV-bicuspid aortic valve, RVOT- right ventricular outflow tract, PV- pulmonary valve, LA- left atrium, VEG-vegetation.
Figure 10: CW (continuous wave ) Doppler showing the acute severe aortic regurgitation (arrow) in a 17-year old female.
Figure 11: Color M-mode (green line) showing the acute severe aortic regurgitation (arrow-AR jet) in a 17-year old female.
Figure 12: Apical view showing the dilated left ventricle and a normal left atrium in a 17-year old female in acute severe aortic regurgitation.
Figure 13: M-mode LV study (green line) showing moderate LV dysfunction with an ejection fraction of 42% in a 17-year old female in acute severe aortic regurgitation.
Figure 14: Suprasternal view showing the prominent aortic arch in a 17-year old female in acute severe aortic regurgitation.
Figure 15: Suprasternal view showing the holodiastolic flow reversal (arrow) of severe aortic regurgitation [7] in a 17-year old female.
A 17-year-old female was brought to the emergency room with a history of sudden onset of breathlessness. Her pulse rate was 87 bpm and blood pressure 110/60 mmHg. She had a history of rheumatic fever during childhood, an episode of febrile illness for 10 days and taken antibiotic treatment recently. Blood chemistry revealed normal and blood cultures were negative. ECG revealed normal as shown in Figure 1 and X-ray chest revealed dilated LV (left ventricle) as in Figure 2. Physical examination revealed grade 3/6 early diastolic murmur over left mid sternal border, basal crackles over lung fields and no peripheral signs of wide pulse pressure. Transthoracic echocardiography revealed vegetations on anterior and posterior leaflets of aortic valve as in Figure 3 and Figure 4, with a “kissing-type “as in Figures 5, 6 and 8. The aortic valve was bicuspid with an attached vegetation as in Figure 9 and it was severely regurgitant as in Figure 10 and Figure 11. The left ventricle is dilated as in Figure 12 with moderate LV dysfunction as in Figure 13. The thoracic aorta was prominent as in Figure 14 with a ‘holodiastolic flow reversal’ as in Figure 15. The patient was treated with digoxin (0.25 mg, half daily), diuretics (Injection. Furosemide 20 mg IV twice daily), ACE inhibitors (tablet. Enalapril 2.5 mg twice daily) along with 2 weeks course of intravenous (IV) cefotaxime (1g) and amickacin (500mg) twice daily and advised aortic valve replacement at the earliest with lifelong penicillin prophylaxis and continuation of antibiotics for 6 weeks since the vegetations remain stable after 2 weeks of treatment, but without any embolic episodes.
Figure 1: Showing the normal ECG in acute severe aortic regurgitation in a 17-year-old female
Figure 2: X-ray chest PA (postero-anterior) view showing the dilated left ventricle due to acute severe aortic regurgitation [6] in a 17-year old female.
Figure 3: Parasternal long axis view showing the vegetation on the anterior leaflet of aortic valve (arrows) in a 17-year old female.
Figure 4: Parasternal long axis view showing the vegetation on the posterior leaflet of aortic valve (arrow) in a 17-year old female. AV-aortic valve.
Figure 5: Parasternal long axis view showing the “ kissing-type” of vegetations (arrow) on the aortic valve in a 17-year old female.
Figure 6: Parasternal long axis view showing the “ kissing-type” of vegetations (arrows) on the aortic valve in a 17-year old female- large view.
Figure 7: Apical view showing the vegetation on the aortic valve (arrow) in a 17-year old female.
Figure 8: Apical view showing the “ kissing-type” of vegetations (arrow) on the aortic valve in a 17-year old female.
Figure 9: Short axis view showing the bicuspid aortic valve with vegetation (arrow) in a 17-year old female. AO-aorta, BCAV-bicuspid aortic valve, RVOT- right ventricular outflow tract, PV- pulmonary valve, LA- left atrium, VEG-vegetation.
Figure 10: CW (continuous wave ) Doppler showing the acute severe aortic regurgitation (arrow) in a 17-year old female.
Figure 11: Color M-mode (green line) showing the acute severe aortic regurgitation (arrow-AR jet) in a 17-year old female.
Figure 12: Apical view showing the dilated left ventricle and a normal left atrium in a 17-year old female in acute severe aortic regurgitation.
Figure 13: M-mode LV study (green line) showing moderate LV dysfunction with an ejection fraction of 42% in a 17-year old female in acute severe aortic regurgitation.
Figure 14: Suprasternal view showing the prominent aortic arch in a 17-year old female in acute severe aortic regurgitation.
Figure 15: Suprasternal view showing the holodiastolic flow reversal (arrow) of severe aortic regurgitation [7] in a 17-year old female.
Review of literature
In 1885, William Osler presented the first comprehensive description of endocarditis. Thereafter, the description of clinical features of infective endocarditis were largely based on data obtained several decades ago. At present, definite clinical evidence of vulnerable infection is based on retrieval of an organism via blood cultures. The ability of echocardiography to detect valvular vegetation was initially described by Dillon and coworkers [8] who identified characteristic thickened echoes, on the mitral and aortic leaflets in patients with tissue -documented valvular lesion.
Etiopathogenesis
The majority of cases of infective endocarditis are caused by gram-positive bacteria, the staphylococcus aureus is now more common than oral streptococci (streptococcus viridians) and it has become the most frequent microorganism causing infective endocarditis (31-54%). Methicillin-sensitive sytaphylococcus aureus (MSSA) is more frequently isolated in community-acquired infective endocarditis, affects mainly native valves, and it is associated with bacteremia of unknown origin, whereas Methicillin-resistant staphylococcus aureus (MRSA) is predominantly related to nosocomial infection, wound infection, IV catheters and surgical procedures. Viridans group is now less common (17-26%) and had partial resistance to antibiotics (‘penicillin tolerence’). The slow-growing HACEK group is an unusual cause of infective endocarditis (1.8-3%) and affects mainly the native valves. Patients with IV drug abusers and long-term central venous catheters are at high risk of fungal infective endocarditis (1-3%), suspected in presence of bulky vegetation, metastatic infection, persistent invasion or embolization to large blood vessels. Whenever blood culture negative infective endocarditis occurs, other organisms such as coxiella burnetti, Brucella, Bartonella, Chlamydia, Streptococcus pneumoniae (often affects the aortic valve [9]) and Legionellae species must be considered. When endothelium is damaged by high flow velocity jets, sterile thrombotic vegetation is formed, which facilitate bacterial adherence during transient bacteremia. Platelet and fibrin deposits at the damaged sites provide the nidus for the formation of vegetation, which causes tissue destruction, septic emboli and abscesses. Vegetation > 1 cm in diameter are associated with greatest risk of embolization [10] and 65 % of embolic events involve the central nervous system, mainly in the distribution of middle cerebral artery (90%). Patients with staphylococcus aureus infective endocarditis have a significant higher incidence of neurologic sequelae (53-71%). Infected embolic material may reach the adventitial layer of an artery through the vasa vasorum, resulting destruction of adventitia and muscularis [11], leading to aneurysm formation [12], usually within 46 hours of embolization [13]. Cerebral infected aneurysms develop in 1 to 12% of cases of infective endocarditis and located on the peripheral branches of middle cerebral artery (55%) [14], also in the secondary and tertiary branches in the region of Sylvian fissure [15] and it is multiple in 18-28% of cases, had saccular type morphology [16] and 10% of them will rupture. Infected intracranial aneurysms may leak slowly or enlarge before rupture and manifest as cranial nerve palsy, seizures, headache and nuchal rigidity due to meningeal irritation. In addition, vegetations often occur in conjunction with ulceration, perforation, and even total destruction of valve leaflets [17], producing abrupt valvular regurgitation, manifested clinically by severe hemodynamic changes [18],[19]. Gross elevation of LVEDP (LV end-diastolic pressure), pulmonary hypertension and depressed cardiac output are the characteristic findings. Valvular destruction causing acute regurgitation is the most characteristic lesion leading to heart failure in native valve infective endocarditis [20],[21]. When there is rapid disruption of the anatomic integrity of the aortic valve, the sudden imposition of a large regurgitant volume causes precipitous increase in LV diastolic pressure and a decrease in forward stroke volume, leading to acute pulmonary edema and, on occasion, circulatory collapse. In acute aoric regurgitation, murmurs may not be easily audible, the pulse pressure is usually reduced due to reduction in stroke volume and increased peripheral vascular resistance. The characteristic physical findings of chronic, severe aortic regurgitation (AR) depend on a widened pulse pressure are often absent. Compensated tachycardia helps to shorten diastolic time available to regurgitation to occur and so the cardiac output is often maintained. Early closure of mitral valve (ECMV) is a specific feature of acute onset, severe aortic regurgitation [22], first postulated by Austin Flint in 1886 [23] and observed echocardiographically by Pride in 1971 [24]. Normally, the mitral valve does not close until shortly after the onset of LV contraction, and leaflet closure occurs 40 ms after the onset of QRS complex in ECG. When the coaptation of both anterior and posterior mitral leaflets occur at or before the initial description of QRS (50 ms before the Q wavem but after the P wave, it is mild (grade 1) and upto 200 ms before the Q wave, it is very marked (grade II) [25]. The premature mitral valve closure is beneficial in the sense that the high LVDP (LV diastolic pressure) is not transmitted to the pulmonary venous system, thus preventing pulmonary edema and left heart failure. When LVDP exceeds the LA pressure, the protection offered by premature mitral valve closure is lost, the opening of mitral valve occurs in late diastole, leading to diastolic mitral regurgitation which is usually effective to lower the LVDP and thus left atrium serves as a reservoir for blood regurgitant from the aorta to left ventricle.
The differential features of acute and chronic AR are shown in Table 1.
| Acute AR | Chronic AR | |
Heart rate
Systemic arterial pulse pressure
Aortic systolic pressure
Aortic diastolic pressure
Peripheral vascular resistance
LV compliance
LV end diastolic pressure
LV ejection velocity
Regurgitant volume
Effective stroke volume
Effective cardiac output
Ejection fraction | Increased
not significantly increased
not increased
not decreased
increased
not increased
markedly increased
not significantly increased
increased
not increased
decreased
not increased | may be normal
increased
increased
markedly decreased
decreased
increased
normal
increased
increased
increased
may be normal
maintained normal for long periods
|
(Table 1 showing the differential features of acute and chronic AR)
In left-sided endocarditis, vegetations usually develop on the edges of the valve leaflets, more prone for peripheral embolism and embolic events may occur before the clinical recognition of the disease as ‘silent
embolism’, especially in spleen and kidney, and 30% of patients have renal or splenic infarcts at the time of diagnosis. Renal function may deteriorate as the result of worsening hemodynamics and emboli to kidney can lead to abscess formation, presenting as flank pain, pyuria, or hematuria and cause ‘flea-bitten” appearance of cortex with focal segmental necrosis of the glomerular tuft [26].
Echocardiographic features
Echocardiography plays a key role in the diagnosis of infective endocarditis and the vegetation, the hallmark lesion of infective endocarditis is a majpr echocardiographuc criterion for its detection. Vegetation is a bulky, friable, frequently pedunculated mass composed of fibrin strands, platelets, blood cell debris, bacteria and presents as an oscillating mass attached to a valvular structure, with a motion independent to that of the valve. It may also presents as non-oscillating
masses with atypical location. Transthoracic echocardiography detects 70% of vegetations > 6 mm and 25% of vegetation < 5>Figures 3 to 9. When endocarditis involves the aortic leaflets, the resultant acute, severe regurgitation as shown in Figures 10, 11 and 15, may often causes dilated left ventricle as in Figure 12 and a prominent aorta as in Figure 14. Secondary infection of mitral valve is a possible finding in primary aortic valve endocarditis. Large aortic valve vegetations (> 6 mm) prolapse into the left ventricular outflow tract and “kiss” the ventricular surface of the anterior mitral leaflet with the development of a vegetation [27],[28],[29]. The left ventricular outflow tract endocarditis may represent the initial site of infection with a possibility to spread by contiguity to both left-sided valves, the mitral and aortic [30], causes the “mitral-kissing vegetation” with a higher prevalence of embolic events [31].
Management
Endocarditis normally presents with fever, murmur, tachypnea, tachycardia, hyperfibrinogenemia, anemia and leukocytosis [32].[33]. Early and adequate diagnosis is important for the prognosis and treatment of patients with infective endocarditis. New laboratory and molecular analysis techniques have been adapted for recognizing previously unidentified species as etiological agents of infective endocarditis. The management of infective endocarditis comprises antibiotic therapy, intensive medical care and surgery as three main pillars of treatment.
Medical therapy
Bacterial endocarditis must be treated with antibiotics. The objective is the selection of antibiotic based on the sensitivity shown by the antibiogram, but treatment generally begins with an empirical wide-spectrum antibiotic until the hemoculture results are ready [34]. Antibiotics commonly used are penicillin associated with gentamycin [35] and the treatment duration depends on the improvement and resolution of clinical signs, echocardiographic findings, white blood cells, and fibrinogen reduction within normal limits. Traditionaly, prolonged ( 4-6 weeks) treatment is mandatory to kill the dormant bacteria clustered in the infected foci [36]. The mean duration of antibiotic therapy was 5 weels and it is possible that similar results can be obtained after as little as two weeks of therapy [37],[38],[39], especially in uncomplicated NVE (native valve endocarditis) with normal renal function [40]. Almost all patients with acute aortic regurgitation (AR) exhibit tenuous hemodynamics and initial stabilization is required in the intensive care unit. Medical therapy is directed at reducing pulmonary venous congestion, reduction in systolic blood pressure to relieve the afterload and maximizing the cardiac output. Intravenous vasodilator and diuretic therapy can be effective and the principal aim of medical treatment is to optimize clinical status. The nitroprusside with an initial dose of 0.10 to 0.20 mg/kg/mt, gradually increased to attain the desired hemodynamic effects as a reduction in LV filling pressure to 15 mmHg or less and an increase in cardiac output that would ensure adequate tissue oxygen delivery, usually a cardiac index > 2.5 L/mt/m2 while maintaining a systemic blood pressure of ³ 90 mmHg. Patients with grade I premature mitral valve closure without clinical heart failure can be managed by medical therapy. Anticoagulation is not indicated for patients with endocarditis because of the risk of hemorrhagic neurological events [41]. It prevents neither the formation nor the embolization of vegetation as separation of small fragments from the infected vegetations. Three quarters of embolism occurs before the beginning of antibiotic treatment [42] and the embolic risk decreases over time, from 15
Since the patient had a bicuspid aortic valve as shown in Figure 9 and a history of rheumatic fever during childhood, rheumatic inflammation occurred on the aortic valve and harboured the infective vegetation through the vascular access during the treatment of febrile episodes. Patients with infective endocarditis are at risk of developing acute aortic regurgitation and the ECG can appear normal as in Figure 1 and the chest X-ray usually shows pulmonary edema with normal heart size. A dilated left ventricular cavity with a normal left atrium as in Figure 12 indicates that the volume overload on the left ventricle resulted a compensatory mechanism to maintain an adequate forward stroke volume by accomodating a large regurgitant fraction without an increase in end-diastolic pressure. The heart rate appeared normal (87 bpm) as the result of this compensation. Even though the aortic regurgitation is acute as in Figure 10 which showed a steep deceleration slope with a narrow width of regurgitant jet due to endocarditic lesion of aortic valve (endocarditic regurgitation). It is compensated in this patient and showed a lesser degree of decompensation as moderate LV dysfunction with an ejection fraction of 42% as in Figure 13, necessitating elective aortic valve replacement along with removal of vegetations with a mechanical prosthetic valve. Anticoagulation with warfarin to maintain the INR (international normailised ratio) between 2 to 3 is indicated after the clearance of active stage of endocarditis with antibiotic therapy and surgery.
Complicated left-sided native valve infective endocarditis remain a serious disease with significant mortality and morbidity. Vascular-access-related infections are major source of bacteremia in this population [77]. Antimicrobial therapy can offer a curative treatment in only 50% of cases of infective endocarditis. Patients with large vegetations, intracardiac abscess (9-14 %) or persisting infection (9-11 %) almost always need surgery and most patients require valve replacement.
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Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.
Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.
Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”
Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner
My Testimonial Covering as fellowing: Lin-Show Chin. The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews.
My experience publishing in Psychology and Mental Health Care was exceptional. The peer review process was rigorous and constructive, with reviewers providing valuable insights that helped enhance the quality of our work. The editorial team was highly supportive and responsive, making the submission process smooth and efficient. The journal's commitment to high standards and academic rigor makes it a respected platform for quality research. I am grateful for the opportunity to publish in such a reputable journal.
My experience publishing in International Journal of Clinical Case Reports and Reviews was exceptional. I Come forth to Provide a Testimonial Covering the Peer Review Process and the editorial office for the Professional and Impartial Evaluation of the Manuscript.
I would like to offer my testimony in the support. I have received through the peer review process and support the editorial office where they are to support young authors like me, encourage them to publish their work in your esteemed journals, and globalize and share knowledge globally. I really appreciate your journal, peer review, and editorial office.
Dear Agrippa Hilda- Editorial Coordinator of Journal of Neuroscience and Neurological Surgery, "The peer review process was very quick and of high quality, which can also be seen in the articles in the journal. The collaboration with the editorial office was very good."
I would like to express my sincere gratitude for the support and efficiency provided by the editorial office throughout the publication process of my article, “Delayed Vulvar Metastases from Rectal Carcinoma: A Case Report.” I greatly appreciate the assistance and guidance I received from your team, which made the entire process smooth and efficient. The peer review process was thorough and constructive, contributing to the overall quality of the final article. I am very grateful for the high level of professionalism and commitment shown by the editorial staff, and I look forward to maintaining a long-term collaboration with the International Journal of Clinical Case Reports and Reviews.
To Dear Erin Aust, I would like to express my heartfelt appreciation for the opportunity to have my work published in this esteemed journal. The entire publication process was smooth and well-organized, and I am extremely satisfied with the final result. The Editorial Team demonstrated the utmost professionalism, providing prompt and insightful feedback throughout the review process. Their clear communication and constructive suggestions were invaluable in enhancing my manuscript, and their meticulous attention to detail and dedication to quality are truly commendable. Additionally, the support from the Editorial Office was exceptional. From the initial submission to the final publication, I was guided through every step of the process with great care and professionalism. The team's responsiveness and assistance made the entire experience both easy and stress-free. I am also deeply impressed by the quality and reputation of the journal. It is an honor to have my research featured in such a respected publication, and I am confident that it will make a meaningful contribution to the field.
"I am grateful for the opportunity of contributing to [International Journal of Clinical Case Reports and Reviews] and for the rigorous review process that enhances the quality of research published in your esteemed journal. I sincerely appreciate the time and effort of your team who have dedicatedly helped me in improvising changes and modifying my manuscript. The insightful comments and constructive feedback provided have been invaluable in refining and strengthening my work".
I thank the ‘Journal of Clinical Research and Reports’ for accepting this article for publication. This is a rigorously peer reviewed journal which is on all major global scientific data bases. I note the review process was prompt, thorough and professionally critical. It gave us an insight into a number of important scientific/statistical issues. The review prompted us to review the relevant literature again and look at the limitations of the study. The peer reviewers were open, clear in the instructions and the editorial team was very prompt in their communication. This journal certainly publishes quality research articles. I would recommend the journal for any future publications.
Dear Jessica Magne, with gratitude for the joint work. Fast process of receiving and processing the submitted scientific materials in “Clinical Cardiology and Cardiovascular Interventions”. High level of competence of the editors with clear and correct recommendations and ideas for enriching the article.
We found the peer review process quick and positive in its input. The support from the editorial officer has been very agile, always with the intention of improving the article and taking into account our subsequent corrections.
My article, titled 'No Way Out of the Smartphone Epidemic Without Considering the Insights of Brain Research,' has been republished in the International Journal of Clinical Case Reports and Reviews. The review process was seamless and professional, with the editors being both friendly and supportive. I am deeply grateful for their efforts.
To Dear Erin Aust – Editorial Coordinator of Journal of General Medicine and Clinical Practice! I declare that I am absolutely satisfied with your work carried out with great competence in following the manuscript during the various stages from its receipt, during the revision process to the final acceptance for publication. Thank Prof. Elvira Farina
Dear Jessica, and the super professional team of the ‘Clinical Cardiology and Cardiovascular Interventions’ I am sincerely grateful to the coordinated work of the journal team for the no problem with the submission of my manuscript: “Cardiometabolic Disorders in A Pregnant Woman with Severe Preeclampsia on the Background of Morbid Obesity (Case Report).” The review process by 5 experts was fast, and the comments were professional, which made it more specific and academic, and the process of publication and presentation of the article was excellent. I recommend that my colleagues publish articles in this journal, and I am interested in further scientific cooperation. Sincerely and best wishes, Dr. Oleg Golyanovskiy.
Dear Ashley Rosa, Editorial Coordinator of the journal - Psychology and Mental Health Care. " The process of obtaining publication of my article in the Psychology and Mental Health Journal was positive in all areas. The peer review process resulted in a number of valuable comments, the editorial process was collaborative and timely, and the quality of this journal has been quickly noticed, resulting in alternative journals contacting me to publish with them." Warm regards, Susan Anne Smith, PhD. Australian Breastfeeding Association.
Dear Jessica Magne, Editorial Coordinator, Clinical Cardiology and Cardiovascular Interventions, Auctores Publishing LLC. I appreciate the journal (JCCI) editorial office support, the entire team leads were always ready to help, not only on technical front but also on thorough process. Also, I should thank dear reviewers’ attention to detail and creative approach to teach me and bring new insights by their comments. Surely, more discussions and introduction of other hemodynamic devices would provide better prevention and management of shock states. Your efforts and dedication in presenting educational materials in this journal are commendable. Best wishes from, Farahnaz Fallahian.
Dear Maria Emerson, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews, Auctores Publishing LLC. I am delighted to have published our manuscript, "Acute Colonic Pseudo-Obstruction (ACPO): A rare but serious complication following caesarean section." I want to thank the editorial team, especially Maria Emerson, for their prompt review of the manuscript, quick responses to queries, and overall support. Yours sincerely Dr. Victor Olagundoye.
Dear Ashley Rosa, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews. Many thanks for publishing this manuscript after I lost confidence the editors were most helpful, more than other journals Best wishes from, Susan Anne Smith, PhD. Australian Breastfeeding Association.
Dear Agrippa Hilda, Editorial Coordinator, Journal of Neuroscience and Neurological Surgery. The entire process including article submission, review, revision, and publication was extremely easy. The journal editor was prompt and helpful, and the reviewers contributed to the quality of the paper. Thank you so much! Eric Nussbaum, MD
Dr Hala Al Shaikh This is to acknowledge that the peer review process for the article ’ A Novel Gnrh1 Gene Mutation in Four Omani Male Siblings, Presentation and Management ’ sent to the International Journal of Clinical Case Reports and Reviews was quick and smooth. The editorial office was prompt with easy communication.
Dear Erin Aust, Editorial Coordinator, Journal of General Medicine and Clinical Practice. We are pleased to share our experience with the “Journal of General Medicine and Clinical Practice”, following the successful publication of our article. The peer review process was thorough and constructive, helping to improve the clarity and quality of the manuscript. We are especially thankful to Ms. Erin Aust, the Editorial Coordinator, for her prompt communication and continuous support throughout the process. Her professionalism ensured a smooth and efficient publication experience. The journal upholds high editorial standards, and we highly recommend it to fellow researchers seeking a credible platform for their work. Best wishes By, Dr. Rakhi Mishra.
Dear Jessica Magne, Editorial Coordinator, Clinical Cardiology and Cardiovascular Interventions, Auctores Publishing LLC. The peer review process of the journal of Clinical Cardiology and Cardiovascular Interventions was excellent and fast, as was the support of the editorial office and the quality of the journal. Kind regards Walter F. Riesen Prof. Dr. Dr. h.c. Walter F. Riesen.
Dear Ashley Rosa, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews, Auctores Publishing LLC. Thank you for publishing our article, Exploring Clozapine's Efficacy in Managing Aggression: A Multiple Single-Case Study in Forensic Psychiatry in the international journal of clinical case reports and reviews. We found the peer review process very professional and efficient. The comments were constructive, and the whole process was efficient. On behalf of the co-authors, I would like to thank you for publishing this article. With regards, Dr. Jelle R. Lettinga.
Dear Clarissa Eric, Editorial Coordinator, Journal of Clinical Case Reports and Studies, I would like to express my deep admiration for the exceptional professionalism demonstrated by your journal. I am thoroughly impressed by the speed of the editorial process, the substantive and insightful reviews, and the meticulous preparation of the manuscript for publication. Additionally, I greatly appreciate the courteous and immediate responses from your editorial office to all my inquiries. Best Regards, Dariusz Ziora
