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Review Article | DOI: https://doi.org/10.31579/2641-0419/553
Division of Cardiology, Monaldi Hospital Naples – Italy.
*Corresponding Author: Chiara Sordelli, Division of Cardiology, Monaldi Hospital Naples – Italy.
Citation: Chiara Sordelli, Emanuele Cigala, Simona Covino , Mario Crisci , Riccardo Granata , et al, (2026), Functional Mitral Regurgitation: Review of Literature and Institutional Therapeutic Strategy, J Clinical Cardiology and Cardiovascular Interventions, 9(4); DOI:10.31579/2641-0419/553
Copyright: © 2026, Chiara Sordelli. 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 February 2026 | Accepted: 02 March 2026 | Published: 06 March 2026
Keywords: mitral regurgitation; drugs; cardiac resynchronization device therapy (CRT); functional mitral regurgitation (M-TEER)
Functional mitral regurgitation (FMR) is associated with poor prognosis and increased morbidity in patients with left ventricular remodelling or atrial dilatation. The review is focused on the current evidence and guideline-based treatments for patients with FMR. Optimal management of patients with FMR requires early initiation and optimization of guideline-directed medical therapy (GDMT), evaluation of indication for cardiac resynchronization therapy (CRT), and timely evaluation for surgical or percutaneous intervention. A stepwise approach tailored to MR mechanism, ventricular geometry, and patient comorbidity is essential. In this paper we present a review on literature and a practical approach for the management of FMR based on currently available evidence.
Mitral regurgitation (MR) is a common pathological condition worldwide and one of the most frequent typeof heart valve disease. It affects approximately 2.5% of the total population and its progression can lead to left ventricular (LV) enlargement and dysfunction, congestive heart failure and death [1]. Mitral regurgitation can be classified as primary or secondary. It is defined primary when it is due to alterations ofthe valve leaflets, chordae tendinae and annulus, while it is secondary or functional (FMR) when due to changes in the left atrium (LA), left ventricle (LV) or mitral valve annulus. FMR can be further classified in atrial (AFMR), ventricular (VFMR) and mixed FMR [2]. For FMR the main treatment is guidelines-directed medical theraphy (GDMT) and cardiac resynchronization (CRT) although some cases can benefit from surgical or percutaneous edge-to-edge transcatheter mitral valve repair. In current era M-TEER can be considered the gold standard therapy for high-risk patients with FMR [2].
Imaging for evaluation of FMR
Transthoracic echocardiography (TTE) is the initial imaging modality for the assessment of FMR; Transoesophageal echocardiography (TOE) may be required in cases of suboptimal TTE images or when is needed a more detailed evaluation of the mitral apparatus. Transoesophageal echocardiography (TOE) represents the method of choice to assess valve anatomy, leaflet quality, motion, and coaptation, as well as to confirm MR severity. Three-dimensional TOE provides an excellent morphological and functional view of the different valve segments, and should be used systematically when planning and performing surgical or transcatheter repair (Figure.1-2). Echocardiographic assessment of MR severity is based on a multi-parametric approach with qualitative, semi-quantitive and quantitative methods (Figure.3). Between semiquantive signs, vena contracta width is one of the best measures considering a cut-off of 7 mm to define severe FMR. Among the quantitative parameters, it is necessary to consider an effective regurgitant orifice area (EROA), a regurgitant volume (RVol) and a regurgitant fraction (RF). According the current European Society of Cardiology guidelines, we can define MR as severe if EROA is > 40 mm2, the RVol > 60 ml and the RF>50% [2]. When quantifying EROA and RVol in FMR, lower thresholds may apply to define severe regurgitation because of the potential elliptical regurgitant orifice and/or the low-flow state. Stress echocardiography is another modality used to assess FMR as regurgitation severity often increases during exercise due to elevated afterload or worsening tethering forces [1-4].
Ventricular Functional Mitral Regurgitation
VFMR is due to LV distortion and dysfunction and can be further classified as either ischemic or nonischemic. The ischemic form which is the most frequent etiology results from papillary muscle displacement causing systolic symmetric or asymmetric tenting of the MV [1]. Symmetric tethering is associated with substantial systolic dysfunction, global remodeling, and increased LV sphericity with a central regurgitant jet. Asymmetric tethering most frequently results from localized remodeling affecting the posterior papillary muscle with posterior leaflet tenting and a posteriorly directed MR jet. Non ischemic MR, instead, is caused by long standing hypertension or idiopathic dilated cardiomyopathy and is characterized by global LV dilation with increased sphericity and a central regurgitant jet. The severity of FMR is dynamic and varies during the cardiac cycle and is also influenced by changes in loading conditions and inducible reversible ischemia [3].
Patients with mild/moderate MR at rest, indeed, can worsen with exercise and supine positioning for increase venous return or can worsen with systemic hypertension for increases afterload. Stress-induced ischemia of the inferior or inferolateral wall leads to worsening of leaflet tethering and subsequent MR. This variability in the degree of FMR should be taken into consideration when considering other imaging techniques, such as stress echocardiography, to assess the severity of FMR in addition to TTE [3].
Guidelines-directed medical therapy (GDMT)
Since FMR occurs secondary to LV dysfunction, pharmacological therapy to optimize LV remodeling is the first line of treatment (Tab.1). All patients should receive GDMT for heart failure with reduced ejection fraction (HFrEF). The availability of four main classes of medication in the armamentarium of GDMT has focused research interest on simple mechanisms to safely and effectively initiate these four classes rapidly. Several authors have proposed rapid optimisation protocols designed to rapidly establish patients onto these ‘four pillars’ of heart failure therapy (beta- blocker (BB), ACE inhibitor/ angiotensin II receptor blocker/ARNI, SGLT2 inhibitor, mineralocorticoid receptor antagonist (MRA)).However, in the real world, GDMT is initiated in only a fraction of patients with HFrEF and it is mostly underdosed, compared with the doses reached in randomized clinical trials (RCTs). Triple GDMT with ARNI, beta-blockers, and MRA was prescribed in 40% of patients undergoing M-TEER in the European Registry of Transcatheter Repair for Secondary Mitral Regurgitation (EuroSMR) registry and was associated with higher survival after mitral transcatheter edge-to-edge repair (M-TEER) [4]. Heart failure guidelines recommend rapid GDMT uptitration with achievement of the maximum tolerated dose within 6 weeks and it’s advisable to re-evaluate patients after 1–3 months [3].
Cardiac resynchronization device therapy (CRT)
Cardiac resynchronization therapy is an established treatment for patients with symptomatic HF despite GDMT and is indicated in patients with New York Heart Association Class II–IV, reduced LVEF ≤ 35%, and a QRS duration ≥ 130 ms with a left bundle branch block (LBBB) morphology (Class I indication according to according american and european guidelines) (Table.2). The effects of CRT on FMR are due to improvement of atrioventricular synchrony and LV contractile efficiency and to restore the electomechanical sequence of papillary muscle with a reduction of effective regurgitant orifice area (EROA) [2]. The amount of FMR reduction with CRT ranges from 23% to 35%, and the residual FMR after CRT is associated with adverse clinical outcomes. For this reason, it is important to identify CRT non-responders early, so that residual FMR can be addressed before the disease is too advanced. Therefore, in non-responders CRT patients o with low probability of CRT due to very advanced stages of HF, poor LV viability, disproportionate MR, and myocardial fibrosis), MV intervention should be considered [28]. Instead, in patients with good acute response and intermediate probability of CRT response, FMR should be reassessed after 3 months of follow-up [3].
Percutaneous transcatheter MV repair (M-TEER)
The management of patients with ventricular FMR is complex and should be discussed by a multidisciplinary Heart Team. In patients who continue to be symptomatic despite the adequate GDMT and CRT, surgical or percutaneous intervention may be considered. However, patients with FMR and HFrEF are rarely operated on surgically both for their hight surgical risk and because trials have not demonstrated a benefit of surgery over conservative therapy [5-6]. In this regard, the Multicenter, Randomized, Controlled Study to Assess Mitral vAlve reconsTrucTion for advancEd Insufficiency of Functional or iscHemic ORigiN (MATTERHORN) trial showed that, among patients with heart failure and FMR, transcatheter edge-to-edge repair was non inferior to mitral-valve surgery with respect to a composite of death, rehospitalization for heart failure, stroke, reintervention, or implantation of an assist device in the left ventricle at 1 year [5-7-8]. In current era, M-TEER can be considered the gold standard therapy for patients with severe ventricular MR without concomitant coronary disease (Tab.3). According to the current ESC guidelines 2025, M-TEER is recommended to reduce HF hospitalizations and improve quality of life in haemodynamically stable, symptomatic patients with impaired LVEF (<50>
System in the Treatment of Clinically Significant Functional Mitral Regurgitation), which has the same inclusion criteria as those of the COAPT trial in terms of MR severity, with intermediary criteria COAPT and MITRA-FR in terms of LV dysfunction severity , have demonstrated that, among patients with heart failure with moderate/severe FMR in medical therapy, the addition of M-TEER led to a lower rate of first or recurrent hospitalization for heart failure or cardiovascular death and a lower rate of first or recurrent hospitalization for heart failure at 24 months and better health status at 12 months than medical therapy alone [17-18-19]. The RE-SHAPE-2 trial suggests a broader application of M-TEER in addition to guideline-directed medical therapy in patients with symptomatic HF and moderate to severe functional mitral regurgitation [20-21-22-23-24]. A comparison of the salient baseline characteristics and outcomes from the 3 randomized trials are shown in Table.4.
Other transcatheter mitral interventions
Among the other percutaneous mitral interventios that have received CE mark approval, it must be consider the Tendyne valve which is a transcatheter mitral valve implanted via the transapical approach, through a left anterolateral thoracotomy. Two year outcomes of 100 patients in a non- randomised prospective study reported a 96% technical success rate, reduction in annualised HFH rates and improvement in NYHA class. Compared to the benefits of the procedure, 39% of patients died within the follow- up period and numerous cases of fatal hemorrhages and strokes have been described after the intervention. Furthermore, there are ongoing trials aimed to test the efficacy of this procedure as the SUMMIT prospective trial which is enrolling patients with severe symptomatic MR to be randomly assigned to m-TEER or Tendyne mitral valve replacement. Other percutaneous procedure include the Carillon mitral contour system and the Cardioband system. The first is a mitral annuloplasty device placed in the coronary sinus to reduce the mitral annular dimension and FMR. It is not currently FDA approved and large randomized trials are needed to assess its clinical benefits. The second is a transcatheter annular reduction system which, in a multicentre trial of 62 patients, have shown at 1 year an improvement in symptom and functional status. These devices, however, are in various stages of development and large randomised controlled trials are needed to demonstrate safety, efficacy and long term prognosis [2-3].
Atrial Functional Mitral Regurgitation
Atrial FMR (AFMR) is characterized by marked left atrial dilation which is common in patients with long standing atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF). LA dilatation pulls the annulus and leaflets insertion upwards, causing flattening and restriction of the anterior MV leaflet movement [1]. Echocardiographic criteria include: preserved LVEF (=50%) without regional wall motion abnormalities or leaflet tethering; no or mildly dilated LV cavity, mitral annulus (MA) and left atrium (LA) dilation [2]. AFMR may have a better prognosis than VFMR but management of AFMR is not clear because of its complicated pathophysiology and lack of data. The initial therapeutic strategy involves, in the case of AF, the restoration of sinus rhythm which can be achieved through various strategies (antiarrhythmic drugs cardioversion, catheter ablation) or GDMT for HFpEF. However, in severe symptomatic patients, refractory to medical/rhythm therapy, M-TEER find application proving to be effective as it brings to positive reverse remodeling of LA and mitral annular dimension [2].
FMR is a complex and dynamic condition where the best treatment depends on its cause, severity, ventricular geometry, the patient’s overall condition, timely diagnosis, optimal medical therapy, and precise patient selection for intervention. There’s no single “one-size-fits-all” option, the current scientific evidence suggest a stepwise and mechanism-driven approach. We propose our therapeutic algorithm guided by the guidelines finalized to rapidly optimise patients with FMR and early identify ‘non- responders’ patients in order to direct them to device therapy reducing morbidity and mortality (Figure.3).
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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
Dear Chrystine Mejia, Editorial Coordinator, Journal of Neurodegeneration and Neurorehabilitation, Auctores Publishing LLC, We would like to thank the editorial team for the smooth and high-quality communication leading up to the publication of our article in the Journal of Neurodegeneration and Neurorehabilitation. The reviewers have extensive knowledge in the field, and their relevant questions helped to add value to our publication. Kind regards, Dr. Ravi Shrivastava.
Dear Clarissa Eric, Editorial Coordinator, Journal of Clinical Case Reports and Studies, Auctores Publishing LLC, USA Office: +1-(302)-520-2644. I would like to express my sincere appreciation for the efficient and professional handling of my case report by the ‘Journal of Clinical Case Reports and Studies’. The peer review process was not only fast but also highly constructive—the reviewers’ comments were clear, relevant, and greatly helped me improve the quality and clarity of my manuscript. I also received excellent support from the editorial office throughout the process. Communication was smooth and timely, and I felt well guided at every stage, from submission to publication. The overall quality and rigor of the journal are truly commendable. I am pleased to have published my work with Journal of Clinical Case Reports and Studies, and I look forward to future opportunities for collaboration. Sincerely, Aline Tollet, UCLouvain.
Dear Ms. Mayra Duenas, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews. “The International Journal of Clinical Case Reports and Reviews represented the “ideal house” to share with the research community a first experience with the use of the Simeox device for speech rehabilitation. High scientific reputation and attractive website communication were first determinants for the selection of this Journal, and the following submission process exceeded expectations: fast but highly professional peer review, great support by the editorial office, elegant graphic layout. Exactly what a dynamic research team - also composed by allied professionals - needs!" From, Chiara Beccaluva, PT - Italy.
Dear Maria Emerson, Editorial Coordinator, we have deeply appreciated the professionalism demonstrated by the International Journal of Clinical Case Reports and Reviews. The reviewers have extensive knowledge of our field and have been very efficient and fast in supporting the process. I am really looking forward to further collaboration. Thanks. Best regards, Dr. Claudio Ligresti
Dear Chrystine Mejia, Editorial Coordinator, Journal of Neurodegeneration and Neurorehabilitation. “The peer review process was efficient and constructive, and the editorial office provided excellent communication and support throughout. The journal ensures scientific rigor and high editorial standards, while also offering a smooth and timely publication process. We sincerely appreciate the work of the editorial team in facilitating the dissemination of innovative approaches such as the Bonori Method.” Best regards, Dr. Matteo Bonori.
I recommend without hesitation submitting relevant papers on medical decision making to the International Journal of Clinical Case Reports and Reviews. I am very grateful to the editorial staff. Maria Emerson was a pleasure to communicate with. The time from submission to publication was an extremely short 3 weeks. The editorial staff submitted the paper to three reviewers. Two of the reviewers commented positively on the value of publishing the paper. The editorial staff quickly recognized the third reviewer’s comments as an unjust attempt to reject the paper. I revised the paper as recommended by the first two reviewers.
Dear Maria Emerson, Editorial Coordinator, Journal of Clinical Research and Reports. Thank you for publishing our case report: "Clinical Case of Effective Fetal Stem Cells Treatment in a Patient with Autism Spectrum Disorder" within the "Journal of Clinical Research and Reports" being submitted by the team of EmCell doctors from Kyiv, Ukraine. We much appreciate a professional and transparent peer-review process from Auctores. All research Doctors are so grateful to your Editorial Office and Auctores Publishing support! I amiably wish our article publication maintained a top quality of your International Scientific Journal. My best wishes for a prosperity of the Journal of Clinical Research and Reports. Hope our scientific relationship and cooperation will remain long lasting. Thank you very much indeed. Kind regards, Dr. Andriy Sinelnyk Cell Therapy Center EmCell
Dear Editorial Team, Clinical Cardiology and Cardiovascular Interventions. It was truly a rewarding experience to work with the journal “Clinical Cardiology and Cardiovascular Interventions”. The peer review process was insightful and encouraging, helping us refine our work to a higher standard. The editorial office offered exceptional support with prompt and thoughtful communication. I highly value the journal’s role in promoting scientific advancement and am honored to be part of it. Best regards, Meng-Jou Lee, MD, Department of Anesthesiology, National Taiwan University Hospital.
Dear Editorial Team, Journal-Clinical Cardiology and Cardiovascular Interventions, “Publishing my article with Clinical Cardiology and Cardiovascular Interventions has been a highly positive experience. The peer-review process was rigorous yet supportive, offering valuable feedback that strengthened my work. The editorial team demonstrated exceptional professionalism, prompt communication, and a genuine commitment to maintaining the highest scientific standards. I am very pleased with the publication quality and proud to be associated with such a reputable journal.” Warm regards, Dr. Mahmoud Kamal Moustafa Ahmed
Dear Maria Emerson, Editorial Coordinator of ‘International Journal of Clinical Case Reports and Reviews’, I appreciate the opportunity to publish my article with your journal. The editorial office provided clear communication during the submission and review process, and I found the overall experience professional and constructive. Best regards, Elena Salvatore.
Dear Mayra Duenas, Editorial Coordinator of ‘International Journal of Clinical Case Reports and Reviews Herewith I confirm an optimal peer review process and a great support of the editorial office of the present journal
Dear Editorial Team, Clinical Cardiology and Cardiovascular Interventions. I am really grateful for the peers review; their feedback gave me the opportunity to reflect on the message and impact of my work and to ameliorate the article. The editors did a great job in addition by encouraging me to continue with the process of publishing.
Dear Cecilia Lilly, Editorial Coordinator, Endocrinology and Disorders, Thank you so much for your quick response regarding reviewing and all process till publishing our manuscript entitled: Prevalence of Pre-Diabetes and its Associated Risk Factors Among Nile College Students, Sudan. Best regards, Dr Mamoun Magzoub.
International Journal of Clinical Case Reports and Reviews is a high quality journal that has a clear and concise submission process. The peer review process was comprehensive and constructive. Support from the editorial office was excellent, since the administrative staff were responsive. The journal provides a fast and timely publication timeline.
Dear Maria Emerson, Editorial Coordinator of International Journal of Clinical Case Reports and Reviews, What distinguishes International Journal of Clinical Case Report and Review is not only the scientific rigor of its publications, but the intellectual climate in which research is evaluated. The submission process is refreshingly free of unnecessary formal barriers and bureaucratic rituals that often complicate academic publishing without adding real value. The peer-review system is demanding yet constructive, guided by genuine scientific dialogue rather than hierarchical or authoritarian attitudes. Reviewers act as collaborators in improving the manuscript, not as gatekeepers imposing arbitrary standards. This journal offers a rare balance: high methodological standards combined with a respectful, transparent, and supportive editorial approach. In an era where publishing can feel more burdensome than research itself, this platform restores the original purpose of peer review — to refine ideas, not to obstruct them Prof. Perlat Kapisyzi, FCCP PULMONOLOGIST AND THORACIC IMAGING.
Dear Grace Pierce, International Journal of Clinical Case Reports and Reviews I appreciate the opportunity to review for Auctore Journal, as the overall editorial process was smooth, transparent and professionally managed. This journal maintains high scientific standards and ensures timely communications with authors, which is truly commendable. I would like to express my special thanks to editor Grace Pierce for his constant guidance, promt responses, and supportive coordination throughout the review process. I am also greatful to Eleanor Bailey from the finance department for her clear communication and efficient handling of all administrative matters. Overall, my experience with Auctore Journal has been highly positive and rewarding. Best regards, Sabita sinha
Dear Mayra Duenas, Editorial Coordinator of the journal IJCCR, I write here a little on my experience as an author submitting to the International Journal of Clinical Case Reports and Reviews (IJCCR). This was my first submission to IJCCR and my manuscript was inherently an outsider’s effort. It attempted to broadly identify and then make some sense of life’s under-appreciated mysteries. I initially had responded to a request for possible submissions. I then contacted IJCCR with a tentative topic for a manuscript. They quickly got back with an approval for the submission, but with a particular requirement that it be medically relevant. I then put together a manuscript and submitted it. After the usual back-and-forth over forms and formality, the manuscript was sent off for reviews. Within 2 weeks I got back 4 reviews which were both helpful and also surprising. Surprising in that the topic was somewhat foreign to medical literature. My subsequent updates in response to the reviewer comments went smoothly and in short order I had a series of proofs to evaluate. All in all, the whole publication process seemed outstanding. It was both helpful in terms of the paper’s content and also in terms of its efficient and friendly communications. Thank you all very much. Sincerely, Ted Christopher, Rochester, NY.
