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What Remains at the Bottom of the PANDORA's Box?
We read with great interest the research article by Bansal et al showcasing the major adverse cardiac and cerebral events (MACCE) predictive value of a novel preoperative combined adiposity-nutritional index (CANI, or visceral adiposity index [VAI]/prognostic nutritional index [PNI]) in patients undergoing off-pump coronary artery bypass grafting (OPCABG). As a matter of fact, the idea of an objective account of the metabolic–nutritional profile of coronary artery disease (CAD) patients coming for surgical revascularization is commendable. We concur that this study opens up a PANDORA's box of the understated prognostic potential of preoperative metabolic–nutritional evaluation. Nevertheless, we infer that a clarification on certain points would potentially assist the readers of the Journal understand the research findings better.
While the authors seek congruence between the 10.93% incidence of 30-day MACCE in their study and the Kaplan–Meier MACCE-predictive event curves of the much longer 5-year follow-up SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery (SYNTAX) trial,  it remains unclear whether/or not a percentage of their OPCABG patients were subjected to a concomitant carotid endarterectomy (CEA) for carotid artery stenosis (CAS). Understandably, CAS may co-exist with CAD, wherein a simultaneous CEA would only enhance the eventual risk of postoperative MACCE.
Ahead of the fact that the syndrome X patients (28.9% overall incidence, with 22.7% in the non-MACCE and 79.5% in MACCE groups) demonstrate a considerable 43% increase in the mean CANI values as opposed to the non-syndrome X patients in the Bansal et al's study, it would have been equally interesting to witness a comparison of the mean CANI values of the syndrome X patients who landed up with postoperative MACCE and those who did not.
Withstanding the fact that advanced age emerged as an independent MACCE predictor in the authors' analysis, it would be worth to call attention to the increasing research interest in the prognostic implications of computing the geriatric nutritional risk index (GNRI), particularly when Bansal et al employed PNI across all the included age groups to compute the corresponding CANI values.
Lastly, we appreciate the authors' proposition of employing CANI as a performance metric for cardiac pre-habilitation programs, which is quite progressive and relevant to the modern-day context of enhanced recovery after cardiac surgery (ERACS). 
Article published online:
01 June 2022
© 2022. Official Publication of The Simulation Society (TSS), accredited by International Society of Cardiovascular Ultrasound (ISCU). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)
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