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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We thank Drs&#46; Yalta&#44; Otzurk&#44; and Yetin for their interest in our article&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Their letter raises relevant points regarding the natural history and management of coronary artery fistulae &#40;CAF&#41; which could not be addressed due to the size constraints of an &#8216;Image in Cardiology&#8217; case&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The authors infer correctly that this presentation is likely due to a congenital coronary artery fistula &#40;CAF&#41; and resulting coronary artery aneurysm which is far more common than secondary CAF&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2&#44;3</span></a> There was no history of trauma or prior coronary artery intervention&#46; Moreover&#44; physical examination&#44; after investigations and imaging findings did not support a diagnosis of a multisystemic disease&#44; such as vasculitis or connective tissue disorders&#46; Notably&#44; detailed imaging of the vascular tree with three-dimension reconstruction failed to identify any arterial wall abnormalities&#44; stenosis&#44; or aneurysms&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">A coronary steal phenomenon may indeed lead to myocardial ischemia&#59; other important clinical sequalae include heart failure due to volume overload&#44; thrombosis&#44; embolism&#44; bacterial endocarditis&#44; rupture of a dilated coronary artery aneurysm and cardiac tamponade&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2&#44;3</span></a> None were present &#8212; the CAF was an incidental finding&#46; The electrocardiogram did not reveal any signs of ischemia and there was no mandate for stress testing&#46; The size of the coronary artery aneurysm and significant left-to-right shunt were the main determinants of surgical intervention&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Lastly&#44; we agree that there is lack of consistency in the literature regarding giant coronary artery aneurysm criteria&#46; However&#44; the maximum diameter on computed tomography was 58 mm which is consistent with both definitions provided &#40;&#62;20 mm or &#62;50 mm&#41;&#46; Other reference measurements suggested were developed and validated in patients with Kawasaki Disease to account for the growing vasculature in a pediatric population&#46; Nakano et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> put forward the criteria of an internal lumen diameter &#62;8 mm or &#62;4 times that of the adjacent segments&#44; which was replaced by Z-scores to take into account body surface area&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">5&#44;6</span></a> Both rely on accurate measurement of normal adjacent segments which&#44; as the readers will appreciate from the published images&#44; was technically challenging due a combination of a proximal aneurysm and an ectatic coronary artery and thus likely to be inaccurate and non-informative&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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