AUCTORES
Globalize your Research
Research Article | DOI: https://doi.org/10.31579/2693-2156/107
1 Department of Cardiovascular Sciences, University Leuven, Biomedical Sciences Group, KU Leuven, Leuven, Belgium.
2 Department of Cardiac Surgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium.
3 Department of Cardiology, University Hospitals Leuven, KU Leuven, Leuven, Belgium.
4 Department of Anesthesiology, University Hospitals Leuven, KU Leuven, Leuven, Belgium.
*Corresponding Author: Bart Meuris, Herestraat 49, 3000 Leuven, Belgium.
Citation: Marie Lamberigts, Filip Rega, Peter Verbrugghe, Christophe Dubois, Danny Hoogma, et al., (2024), Outcomes of Enhanced Recovery After Sutureless Aortic Valve Replacement in Older Patients, J Thoracic Disease and Cardiothoracic Surgery, 5(5); DOI:10.31579/2693-2156/107
Copyright: © 2024, Bart Meuris. 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: 13 June 2024 | Accepted: 24 July 2024 | Published: 26 August 2024
Keywords: sutureless AVR; Perceval; fast-track recovery; ERACS; older patients
Background/Aim
In surgery, enhanced recovery protocols including minimally invasive surgery and the use of sutureless valves can play an important role to decrease invasiveness and improve outcomes, certainly in older patients. The objective of this study was to analyze outcomes of enhanced recovery after cardiac surgery (ERACS) to older patients after sutureless AVR (SU AVR).
Materials and Methods
We analyzed all patients between 2007 and 2022 who underwent SU-AVR and were included in the ERACS program. The primary outcome was 30-day mortality. Secondary outcome were 5-year survival, postoperative complications and hemodynamic performance.
Results
We identified 237 ERACS patients with a median age of 78 years and the median EuroSCORE II was 2.2%. Isolated AVR accounted for 80.2% of cases, and a minimally invasive approach was used in 70.5% of patients. Thirty-day mortality was 0.4% with a stroke rate of 0.8%. Valves performed well at discharge with a peak and mean gradient of 22.5 mmHg (IQR, 19-29 mmHg) and 12 mmHg (IQR, 10-16 mmHg), respectively. Paravalvular leakage > 1/4 occurred in 0.8% and new pacemaker implantation was needed in 5.1%. Five-year survival was 90.1%.
Conclusions
In a cohort with most patients older than 75 years old, we observed very low rates of both 30-day mortality and stroke, good hemodynamic performance of the sutureless valve and low rates of paravalvular leak or pacemaker need. Sutureless AVR facilitates minimal access surgery and allows for application of a ERACS regime in a wide variety of patients, even in older patient cohort.
According to the most recent guidelines for the management of patients with valvular heart disease, aortic valve replacement is recommended for patients with aortic stenosis [1, 2]. The number of patients diagnosed with aortic stenosis is increasing, due to population aging and improvements in diagnostic imaging [3].
Given the advancing age of many patients, often in combination with increased comorbidity, surgical aortic valve replacement (SAVR) remains to be associated with significant risks, thus driving the need for less invasive options. Transcatheter aortic valve replacement (TAVR), also known as transcatheter aortic valve implantation (TAVI), was first performed in 2002 [4], rapidly becoming the first-line treatment for high surgical risk in older patients [1, 2].
Current guidelines suggest to perform TAVI in patients older than 75 or 80 years old, however, there is still an important fraction of patients for whom this procedure is not recommended, including those with contraindications for TAVR or non-severe aortic stenosis [1, 2]. In addition, indications for TAVI procedures differs across Europe, with reimbursement being limited in some countries [5, 6], highlighting the importance of improving SAVR outcomes. Consequently, SAVR is still an important procedure, but requires further optimization to reduce associated perioperative surgical risks.
In recent years, the adoption of enhanced recovery after surgery (ERAS) protocols has led to shorter patient recovery periods and improvement of postoperative outcomes in many surgical specialties [7-9]. Implementation of ERAS protocols, which focus on maintaining adequate organ function in the perioperative period in a holistic way and reducing the body’s stress response following surgery [10, 11], are steadily gaining momentum, also for heart valve procedures [12, 13]. Specifically for cardiac surgery, the implementation of ERAS (enhanced recovery after cardiac surgery—ERACS) protocols focuses on several aspects of treatment and hospitalization, including early extubation, early drain removal, early ambulation, and a multi-modal pain strategy [14]. While becoming increasingly popular in cardiac surgery, ERACS protocols are quite extensive, so implementation can be gradual. It is also important to note that many patients are not eligible for a full ERACS protocol, due to the complexity of certain procedures and postoperative care, as well as their age [13, 15, 16], but they may still benefit from the implementation of ERACS elements that result in better patient outcomes.
One way to reduce invasiveness of cardiac surgery is to use minimally invasive surgical approaches, such as a mini-sternotomy [17]. Another way is to use sutureless technology for aortic valves, which eliminates the need for sutures after annular decalcification, therefore reducing both aortic cross-clamp (AXC) time and cardiopulmonary bypass (CPB) time [18]. The Perceval aortic valve (Corcym S.r.l, Saluggia, Italy) is a bioprosthetic valve designed with a nitinol alloy frame allowing it to be collapsed for implantation and self-expands in the annulus.
The objective of this study was to analyze outcomes of ERACS to older patients after sutureless AVR (SU‑AVR) at our institution.
Study Design and Patient Selection
This study is a retrospective analysis of all patients who were treated at our institution with the Perceval sutureless valve between 2007 and June 2022 and who were included in our ERACS-program. Patients were not admitted to the intensive care unit after surgery but stayed overnight in the post-anesthesia care unit (PACU), with the additional goals of extubation within six hours, early mobilization, drain removal, peroral intake and removal of deep venous lines [19]. Patients received a routine postoperative follow-up schedule involving blood controls, chest X-ray control and transthoracic echocardiography just before discharge home. After discharge, the patient returns on a cardiology outpatient clinic at 4 weeks after the hospital discharge. Thereafter, next visit will be at 6 months followed by yearly cardiological outpatient visits (including echocardiography).
Inclusion criteria were SU-AVR using the Perceval valve, with or without additional procedures such as coronary artery bypass grafting (CABG) or multiple valve repair/replacement that were part of our PACU-centric ERACS program. Until 2017, guidelines for ERACS inclusion in our institution were age between 18-80 years, being scheduled for single procedures, body mass index (BMI) less than 40 kg/m², left ventricular ejection fraction above 30% and serum creatinine below 2 mg/dl. After January 2018, inclusion criteria were simplified to EuroSCORE II below 3%, age above 16 years, and a BMI below 40 kg/m² [19-22]. Deviation from these inclusion criteria was permitted following an uneventful procedure and assessment of the surgeon and anesthesiologist.
Data on patient’s characteristics, operative information, and follow-up details were retrospectively extracted from patient’s records, in accordance with regulations on data protection. Permission to perform this analysis was granted by the ethics committee UZ/KU Leuven in 7/12/2020, with approval number S64845.
Outcome Measures
The primary outcome measure in this study was 30‑day mortality. Secondary outcome was 5-year survival, postoperative complications and hemodynamic performance using transthoracic echocardiography at discharge. Severe structural valve deterioration (SVD) was defined as presence of central valve insufficiency of >2/4, an increase in mean gradient >20 mm Hg or a mean gradient >40 mm Hg, in accordance with the standardized definitions by ESC/EACTS/EAPCI [23].
Statistical Analysis
Statistical analysis was performed using SPSS version 27 (IBM Corp) and GraphPad Prism version 9.4.0 (GraphPad). The Shapiro‑Wilk test was used to check normality. Continuous data are presented as median and interquartile range (IQR). Categorical data are presented as frequency and percentage. Incidence rates were calculated by the number of events divided by the total patient-years. Long-term survival was estimated and presented using the Kaplan-Meier method.
Between 2007 and June 2022, 237 patients underwent SU‑AVR with the Perceval valve at our institution and followed an ERACS regime. These patients had a median age of 78 years (IQR, 74‑82 years), with 95 (40.1%) patients being octogenarians (Table 1). The median EuroSCORE II was 2.2% (IQR, 1.5-3.1%) and 70 (29.5%) patients had a EuroSCORE II > 3%. The decision for fast-tracking in certain patients deviated from the specified criteria, according with the procedure type (full sternotomy versus minimally invasive approach) or favorable perioperative characteristics. The majority (96.2%) of patients underwent elective surgery, with only 9 (3.8%) needing urgent surgery.
| Age (years) | 78 (74 - 82) |
| Octogenarians | 95 (40.1) |
| Gender (male) | 115 (48.5%) |
| BSA (m²) | 1.8 (1.7 - 2.0) |
| Previous cardiac surgery | 4 (1.7%) |
| IDDM | 10 (4.2%) |
| Recent MI | 3 (1.3%) |
| Receiving dialysis | 1 (0.4%) |
| Chronic lung disease | 29 (12.2%) |
| Peripheral arterial disease | 33 (13.9%) |
| Active endocarditis | 0 (0%) |
| NYHA Class | |
| I | 21 (8.9%) |
| II | 119 (50.2%) |
| III | 92 (38.8%) |
| IV | 5 (2.1%) |
| LV ejection fraction (%) | |
| > 50% | 219 (92.4%) |
| 31-50% | 15 (6.3%) |
| 21-30% | 3 (1.3%) |
| < 21% | 0 (0%) |
| Pulmonary hypertension | |
| <31mmHg | 150 (92.4%) |
| 31-55 mmHg | 15 (6.3%) |
| > 55 mmHg | 3 (1.3%) |
| Urgency | |
| Elective | 228 (96.2%) |
| Urgent | 9 (3.8%) |
| Emergency | 0 (0%) |
| Salvage | 0 (0%) |
| EuroSCORE II (%) | 2.2 (1.5 - 3.1%) |
| Data are presented as median (interquartile range), or n (%). BSA: body surface area; IDDM: insulin-dependent diabetes mellitus; MI: myocardial infarction; NYHA: New York Heart Association; LV: left ventricle; EuroSCORE: European System for Cardiac Operative Risk Evaluation. | |
Table 1: Preoperative characteristics (N=237)
A minimally invasive approach was used in 70.5% of patients and 80.2% were treated with single AVR (Table 2). In 19.8% of patients, surgery was combined, being mainly single CABG. The rate of minimal access surgery within the single AVR group was 90.5%. The median CPB time was 60 minutes (IQR, 50-74 minutes) and the median AXC time was 37 minutes (IQR, 34-47 minutes). The implanted valve type was a Perceval S in 150 (63.3%) patients and a Perceval PLUS in the remaining 87 (36.7%) patients.
| AVR + CABG | 28 (11.8%) |
| Multiple procedures | 19 (8.0%) |
| Access | |
| Full sternotomy* | 63 (26.5%) |
| Mini-sternotomy | 167 (70.5%) |
| Anterior right thoracotomy | 7 (3.0%) |
| Valve Type | |
| Perceval S | 150 (63.3%) |
| Perceval PLUS | 87 (36.7%) |
| Cardiopulmonary bypass time (min) | 60 (50 - 74) |
| Cross-clamp time (min) | 37 (31 - 47) |
| Data are presented as median (interquartile range) or n (%). AVR: Aortic valve replacement; CABG: coronary artery bypass grafting. * 2 patients underwent conversion from MICS to sternotomy. | |
Table 2. Intraoperative characteristics (N=237)
Early Outcomes
All patients stayed overnight in the PACU and the hospitalization period was 7 days (IQR, 6-9 days; Table 3). The 30-day mortality was 0.4% (1 patient) and the rate of major complications was also low, with a stroke rate of 0.8%, reoperation for bleeding in 0.4% and no new need for dialysis. A new pacemaker was needed for 12 (5.1%) patients at 30 days.
| Reoperation for bleeding | 1 (0.4%) |
| Stroke | 2 (0.8%) |
| New dialysis | 0 (0%) |
| Pacemaker rate at 30 days | 12 (5.1%) |
| In hospital mortality | 1 (0.4%) |
| Hospital lenght of stay (days) | 7 (6 - 9) |
| Data are presented as median (interquartile range) or n (%). | |
Table 3. Postoperative events (N=237)
At discharge, the hemodynamic performance of the Perceval valve showed a peak and mean gradient of 22.5 mmHg (IQR, 19-29 mmHg) and 12 mmHg (IQR, 10‑16 mmHg), respectively. Only 2 (0.8%) patients had a mild paravalvular leak (Table 4). Median iEOA was 0.9 cm2/m2 (IQR, 0.8-1.1 cm2/m2).
| Peak gradient (mmHg) | 22.5 (18 - 29) |
| Mean gradient (mmHg) | 12 (10 - 16) |
| EOA (cm²) | 1.7 (1.4 - 2.1) |
| iEOA (cm²/m²) | 0.9 (0.8 - 1.1) |
| PVL > 1/4 | 2 (0.8%) |
| CVL > 1/4 | 2 (0.8%) |
| Data are presented as median (interquartile range) or n (%). EOA: effective orifice area; iEOA: indexed effective orifice area. | |
Table 4. Discharge echocardiography (N=237)
Late Outcomes
The cumulative follow-up was 612.8 patient-years. During follow-up, there where 3 (1.3%) cases of endocarditis, corresponding to an incidence rate of 0.21% per patient-year. All 3 patients underwent reoperation. There were no cases of severe structural valve deterioration. The 5-year survival was 90.1%, and the Kaplan-Meier mean survival estimate was 6.98 ± 0.26 years (Figure 1).
Figure 1. Kaplan-Meier estimate of the cumulative survival of the study population. Dotted lines represent 95% confidence interval and the number at risk are shown in red.
In this study, we observed low rates of 30-day mortality, stroke and reoperation for bleeding in combination with a good hemodynamic performance and low pacemaker rates after sutureless AVR in an ERACS regime.
The current available evidence supports the use of TAVI in high-risk, older patients, although there are some uncertainties regarding long-term outcomes [24]. This is mostly related to the surgical risk of these patients and the subsequent poorer outcomes following a major surgery. However, the determination of surgical risk is not always straightforward, involving a multidisciplinary preoperative assessment of each patient which accounts for age, comorbidities and frailty [25]. Older patients who are not at a high surgical risk can still benefit from surgical AVR, which has excellent long-term outcomes in terms of event-free survival and quality of life, especially when the procedure is minimally invasive [26].
The implementation of ERACS elements in minimally invasive cardiac surgery has shown to be beneficial, even if a full ERACS protocol is not implemented [19, 27]. In our study, the use of a PACU-centric ERACS program and a minimally invasive procedure in the majority of cases resulted in a very low 30-day mortality, as well as a short hospital stay.
The use of SU-AVR with the Perceval valve enables a wider adoption of minimally invasive cardiac surgery as a treatment option for older patients, due to the simple and quick implantation process, with minimal manipulation of the aortic root [28]. In our study, the median CPB and AXC times were 60 and 37 minutes, compared to a median CPB and AXC
times in conventional surgical AVR of 87 and 63 minutes, respectively [29]. This reduction in CPB and AXC times is relevant for all patients, but especially for older patients or those undergoing a repeat intervention [30].
Recently, the DEDICATE trial (Blankenberg et al.) investigated TAVI and SAVR in a low-risk population (mean age 74y, mean STS score 1.8) [31]. In the surgical arm of this German multi-centre study, the 30-day mortality was 1.5% with a stroke rate of 1.7%. Sutureless valves were only used in 12% of cases (explaining longer cross-clamp and CPB times up to 61 and 88min. respectively) and minimal access surgery was used in only 48% of cases. The median hospital stay was 9 days. Our study population shows lower mortality and 30-day complication rates. Of the 237 ERACS patients, 2 (0.8%) had a stroke and none had a transient ischemic attack. There were also no patients with new onset kidney injury requiring dialysis. There were 12 (5.1%) patients requiring a new permanent pacemaker at 30-days post-SU-AVR. This pacemaker rate is lower than previously reported for Perceval in combination with mini-sternotomy but slightly higher than the rate reported with the use of a stented prosthesis and a mini-sternotomy approach [32]. New pacemaker implantation remains a serious complication after surgical and mainly after transcatheter AVR. In a recent study comparing outcomes in a matched cohort of patients undergoing SU-AVR or TAVI, TAVI had much higher rates of permanent pacemaker implantation after the procedure [33].
Regarding valvular function, our results showed a favorable profile after Perceval implantation. As demonstrated before, correct sizing of the valve is very important to ensure optimal transvalvular gradients and limiting pacemaker implantation, while not influencing the incidence of (para)valvular regurgitation [34].
In regard to late complications, reintervention was only due to endocarditis in 3 cases (1.3%), while no cases of severe structural valve deterioration up to 5‑year follow‑up occurred. We recently published the 13‑year follow-up data from our overall Perceval population and valve durability looks promising, with a limited number of structural valve deterioration cases [36]. Although it has been limited, if deterioration occurs, the Perceval valve lends itself well to TAVR valve in valve [36, 37].
Overall, our results show that the addition of an enhanced recovery program to the use of a sutureless valve for AVR (with a majority of minimal access procedures, up to 91% in single AVR) contributes to better patient outcomes, even in older patients.
Limitations
Despite the favorable results in this population of older patients, it is important to note some limitations of the study. The retrospective nature of the analysis, together with the lack of control group and the single-center setting, restrict the generalization of results.
In a cohort with most patients older than 75 years old, we observed very low rates of both 30-day mortality and stroke, good hemodynamic performance of the sutureless valve and low rates of paravalvular leak or pacemaker need. The shortness and simplicity of sutureless AVR allows for application of a ERACS regime in a wide variety of patients, even in an older patient cohort. The combination of ERACS, sutureless valves and minimally invasive surgery is certainly still competitive to transcatheter treatments.
Medical writing support was provided by Dr. Diana Ribeiro, MPharm, and funded by Corcym.
Marie Lamberigts is a PhD student funded by a research grant from Corcym.
Filip Rega, Peter Verbrugghe and Bart Meuris are consultants to Corcym.
Christophe Dubois receives speaker fees from Corcym.
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
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.
