Minimally invasive aortic valve replacement in morbidly obese patients: outcomes from a cohort study and pooled data analysis

Background In the context of cardiac surgery, morbid obesity poses several perioperative challenges. Some surgeons consider obesity a relative contraindication for minimally invasive aortic valve replacement (MIAVR) due to anatomical and technical complexities. Although MIAVR is increasingly used in standard-risk populations, evidence supporting its safety and efficacy in morbidly obese patients remains limited. Methods This retrospective cohort consisted of 920 patients who underwent MIAVR via partial upper ministernotomy at a high-volume cardiac surgery center between 2010 and May 2025. Patients were categorized into three groups based on BMI: Class I obesity (BMI 30–35 kg/m 2 ; n = 164), Class II–III obesity (BMI > 35 kg/m 2 ; n = 54), and a non-obese control group ( n = 702). Key clinical outcomes, echocardiographic parameters, postoperative complications, and long-term mortality rates were compared. Additionally, a pairwise meta-analysis was conducted, incorporating five studies to assess outcomes of MIAVR vs. conventional full sternotomy in obese individuals. Results There were no significant differences in most of postoperative outcomes. However, higher rates of pneumothorax and arrhythmias were observed in Class II–III obesity. Multivariate regression did not identify obesity as an independent predictor of adverse outcomes. Meta-analysis confirmed comparable operative times and a trend toward shorter ICU stays and lower respiratory complications in the MIAVR group. Conclusion This study argues that (i) obesity alone should not delay, deter, or preclude appropriate candidates from being referred for surgical aortic valve replacement, and (ii) partial upper ministernotomy should be considered the preferred access route in obese patients, as it consistently facilitates recovery without compromising safety.