Multivessel coronary artery bypass grafting via small thoracotomy versus sternotomy (MIST) - an investigator-initiated, international, open-label, randomised controlled trial

Sep 21, 2026

Multivessel coronary artery bypass grafting (CABG) is typically performed via median sternotomy, but minimally invasive cardiac surgery (MICS) CABG through small thoracotomy may enhance postoperative recovery. This investigator-initiated, international, open-label randomised controlled trial compared patient-reported physical recovery after MICS CABG versus sternotomy CABG in patients suitable for both approaches. The primary endpoint at 1 month used SF-36 PCS, analyzed by intention to treat, with multiple imputation for missing questionnaire data.

LanguageEnglish

CategoryHealthcare

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Pages10

Reading Time25 min

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Articles Multivessel coronary artery bypass grafting via small thoracotomy versus sternotomy (MIST): an investigatorinitiated, international, open-label, randomised controlled trial Marc Ruel, Sathyaki Nambala, Ming Hao Guo, Alexander Verevkin, Prem Rabindranauth, Keita Kikuchi, Piroze M Davierwala, Massimo Lemma, Menaka Ponnambalam, Azmat Sheikh, Alice Black, Michael A Borger, Richard P Whitlock, Yan Zhang, George A Wells Summary Background Coronary artery bypass grafting (CABG) is a common but invasive operation traditionally performed through a median sternotomy. Minimally invasive cardiac surgery (MICS) CABG via small thoracotomy might improve postoperative recovery, but randomised evidence has been scarce. We aimed to compare patient-reported recovery after MICS CABG versus sternotomy CABG in patients with multivessel coronary artery disease and to describe clinical and safety outcomes. Methods MIST was an investigator-initiated, international, open-label, randomised controlled trial done at seven centres (four academic hospitals and three community hospitals) in Canada, India, China, Germany, the USA, and Japan. Patients referred to participating surgeons for CABG were eligible if they were aged 18 years or older; had angiographically confirmed multivessel coronary artery disease, defined as lesions of at least 70% stenosis in at least two major epicardial vessels and at least two separate coronary artery territories (left anterior descending artery, left circumflex artery, or right coronary artery) or left main coronary stenosis of 50% or more; and were suitable for coronary surgery both with sternotomy CABGand MICS CABG. Patients who were haemodynamically compromised, had contraindications to either approach, had had previous cardiac surgery, or required concomitant procedures were excluded. Eligible patients were randomly assigned (1:1) to MICS CABG or sternotomy CABG by a central, web-based system, stratified by centre, with block sizes of four and six. The primary endpoint was patient-reported physical recovery at 1 month, assessed by the 36-item Short Form Health Survey Physical Component Summary (SF-36 PCS) score. The primary analysis was by intention to treat; safety analyses were done according to treatment received. Missing 1-month questionnaire data were handled by multiple imputation. The trial was registered with ClinicalTrials. gov (NCT03447938), and is closed to recruitment. Findings Between Aug 24, 2018, and Nov 26, 2024, 176 patients were enrolled, 170 of whom were randomly assigned to MICS CABG (n=86) or sternotomy CABG (n=84). The median age of patients was 67·0 years (IQR 61·0–72·0), 154 (91%) patients were male, and 16 (9%) were female. At 1 month after surgery, SF-36 PCS scores were significantly higher in the MICS CABG group than inthe sternotomy CABG group (mean 45·1 [SD 8·0] vs 42·2 [9·1]; mean difference 2·9 [95% CI 0·3–5·5]; p=0·031). Clinical and safety follow-up at 1 month was complete in all patients; 12-month clinical and safety follow-up was complete in all except three patients in the sternotomy CABG group. Up to 12 months after surgery, there were no deaths or strokes in either group; one major adverse cardiac or cerebrovascular event occurred in the MICSCABG group before 1 month and none in the sternotomy CABG group. Interpretation For selected patients with multivessel coronary artery disease, MICS CABG performed by experienced teams improved patient-reported physical recovery at 1 month compared with sternotomy CABG, with no apparent safety penalty through to 12 months. These findings support consideration of MICS CABG in appropriately selected patients treated by experienced teams, and further studies of implementation, recovery pathways, and long-term outcomes. Funding Medtronic. Copyright © 2026 Elsevier Ltd. All rights reserved, including those for text and data mining, AI training, and similar technologies. Introduction Coronary artery bypass grafting (CABG)

FAQs

What is the study comparing in multivessel CABG patients?

The trial compares patient-reported recovery after MICS CABG via small thoracotomy versus conventional sternotomy CABG in patients with multivessel coronary artery disease who are suitable for both approaches.

How was recovery measured and what was the primary endpoint?

The primary endpoint was physical recovery at 1 month, assessed using the 36-item Short Form Health Survey Physical Component Summary (SF-36 PCS) score.

What were the main recovery and safety results at 1 month and up to 12 months?

At 1 month, SF-36 PCS scores were significantly higher with MICS CABG than with sternotomy CABG. Through 12 months, there were no deaths or strokes in either group, with major adverse cardiac or cerebrovascular events reported only in the MICS CABG group before 1 month.

Sep 21, 2026

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