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Interview With Marc Ruel: Thoughts on Minimally Invasive Cardiac Surgery and the MIST Trial

Tuesday, May 29, 2018

Yadava OP, Ruel M. Interview With Marc Ruel: Thoughts on Minimally Invasive Cardiac Surgery and the MIST Trial. May 2018. doi:10.25373/ctsnet.6294788.

Om Prakesh Yadava, of the National Heart Institute in New Delhi, India, interviews Marc Ruel of the University of Ottawa in Canada. Drs Yadava and Ruel discuss minimally invasive cardiac surgery (MICS), its benefit in both the developing and developed world, and the MIST (minimally invasive versus sternotomy) trial.

Dr Marc Ruel feels that cardiac surgery, being a reconstructive and not an ablative specialty, was slow in developing MICS but that it is now on track as even developing countries like India have taken to it with gusto. He encourages collaboration between the developing and developed world. Taking a cue from a recent editorial by Kappetein and Vahanian [1], Dr Ruel discusses the terms, "efficacy" and "effectiveness," where efficacy refers to controlled conditions and effectiveness refers to real life and unmonitored situations. He comments that although MICS is definitely efficacious, effectiveness has yet to be proven. He stresses that specialized centers should be developed and that these procedures should be done, at least at this stage, in those specialized centers.

Dr Yadava asks whether these technologies are relevant to a developing country such as India, given that science must answer to the aspirations of the society and considering the different contexts of cost containment in the western world and India. Dr Ruel responded that these surgeries are all the more important to a developing country like India, as the medical and social networks are not as strong as in other countries and therefore, patients need to get back to work faster. This is one major advantage of MICS: shorter convalescence and early return to gainful employment. Dr Ruel feels that MICS helps society and is therefore relevant to the developing world. Mechanical circulatory support devices and transplantation impact an individual or a family and might even help in the branding of an institution, but they do not produce great benefits to the society at large. Minimally invasive techniques, however, are very relevant to the community and society, especially in the field of coronary artery disease, which is rampant in Southeast Asia.

Dr Ruel then discusses the rationale, inclusion and exclusion criteria, and the primary and secondary end points of the MIST trial. He also discusses the methodology being adopted for the trial, which compares the minimally invasive approach with sternotomy for coronary artery disease. Dr Ruel is the principal investigator of this multicenter international randomized controlled trial. He states that though there is some level of observational data, there is no randomized controlled trial comparing these two approaches to surgically treating coronary artery disease. The MIST trial aims to bridge that gap.


  1. Kappetein AP, Vahanian A. Effectiveness in a real-world observation confirms efficacy of controlled clinical trials. J Am Coll Cardiol. 2017;70(4):451-452.

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