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      We appreciate the interest of Wu et al in our work and welcome their insightful comment.
      • Koratala A.
      • Malpartida F.R.
      • Kamboj M.
      • Alquadan K.F.
      Arteriovenous fistula: an uncommon cause of heart failure.
      In their letter, they describe an interesting case of heart failure resulting from aorta-pulmonary artery fistula in an elderly patient who initially presented with chest discomfort.
      • Wu C.
      • Wu T.
      • Lin H.
      Aorta-aorta fistula: another uncommon cause of heart failure.
      Although the authors do not elaborate on the potential cause, aorta-pulmonary artery fistula can occur secondary to local rupture in the aorta with severe degenerative disease in the setting of an aneurysm, trauma, or infection. As they mentioned, transthoracic echocardiography is a useful diagnostic tool in such cases, whereas confirmation requires demonstration of high oxygen saturation in the pulmonary artery blood and an oxygen step-up between the right atrium and the pulmonary artery on cardiac catheterization.
      • Dixit M.D.
      • Gan M.
      • Narendra N.G.
      • et al.
      Aortopulmonary fistula: a rare complication of an aortic aneurysm.
      It is also noteworthy that major arteriovenous fistulae in any vascular bed resulting in higher flow-to-lower flow shunt can result in high-output cardiac failure. For example, there have been reported cases of heart failure resulting from traumatic popliteal arteriovenous fistula,
      • Trindade V.D.
      • Piantá R.M.
      • Heck A.A.
      • Goldani M.A.
      High-output heart failure resulting from a traumatic arteriovenous fistula.
      aorto-caval fistula,
      • Abreo G.
      • Lenihan D.J.
      • Nguyen P.
      • Runge M.S.
      High-output heart failure resulting from a remote traumatic aorto-caval fistula: diagnosis by echocardiography.
      and renal arteriovenous fistula. The patient reported by Wu et al, coupled with our case and similar previous reports, highlights the need for having a high index of suspicion for arteriovenous fistulae when patients present with otherwise unexplained new-onset heart failure. Appropriate use of imaging studies such as echocardiography, duplex ultrasound, and magnetic resonance imaging could prove helpful for timely diagnosis in this setting, in addition to careful history taking that includes details about previous surgeries and trauma.

      References

        • Koratala A.
        • Malpartida F.R.
        • Kamboj M.
        • Alquadan K.F.
        Arteriovenous fistula: an uncommon cause of heart failure.
        Am J Med. 2018; 131: e47-e48
        • Wu C.
        • Wu T.
        • Lin H.
        Aorta-aorta fistula: another uncommon cause of heart failure.
        Am J Med. 2018; 131: e273-e274
        • Dixit M.D.
        • Gan M.
        • Narendra N.G.
        • et al.
        Aortopulmonary fistula: a rare complication of an aortic aneurysm.
        Tex Heart Inst J. 2009; 36: 483-485
        • Trindade V.D.
        • Piantá R.M.
        • Heck A.A.
        • Goldani M.A.
        High-output heart failure resulting from a traumatic arteriovenous fistula.
        J Vasc Surg. 2015; 61: 1329
        • Abreo G.
        • Lenihan D.J.
        • Nguyen P.
        • Runge M.S.
        High-output heart failure resulting from a remote traumatic aorto-caval fistula: diagnosis by echocardiography.
        Clin Cardiol. 2000; 23: 304-306

      Linked Article

      • Aorta–Aorta Fistula: Another Uncommon Cause of Heart Failure
        The American Journal of MedicineVol. 131Issue 6
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          We read the article “Arteriovenous fistula: an uncommon cause of heart failure,” reported by Koratala et al,1 with great interest. The study reported a 72-year-old patient with arteriovenous fistula that resulted in heart failure. Recently we encountered an 84-year-old patient suffering from aorta–aorta fistula with chest discomfort. The initial chest computed tomography angiography of the patient showed a descending aorta–pulmonary aorta fistula with collateral vessels (Figure). However, the chest pain was considered as unstable angina, for which the patient received 2 coronary stents.
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