Minimally invasive versus sternotomy cardiac surgery in younger adults: the role of body image in health-related quality of life

Abstract

Background

Chest scars after cardiac surgery may be especially important for body image and health-related quality of life (HRQoL) in younger adults, but the impact of minimally invasive versus sternotomy access on these outcomes remains unclear.

Objective

To compare body image and HRQoL after minimally invasive versus sternotomy cardiac surgery in adults younger than 60 years and to explore whether body image may be associated with the relationship between access route and HRQoL.

Methods

In this retrospective cross-sectional study, 47 patients younger than 60 years who had undergone cardiac surgery 4–22 months earlier completed structured interviews. Body image was assessed with the Body Esteem Scale and summarized as a gender-standardized Body Image Score. HRQoL was measured using the EQ-5D-5 L Index Value and EQ-VAS. Nonparametric group comparisons, correlation and regression analyses, and exploratory mediation analysis with bootstrapped confidence intervals were conducted.

Results

EQ-5D Index Values and EQ-VAS scores did not differ significantly between access routes. Patients after minimally invasive surgery reported higher satisfaction with chest appearance and tended to report more favorable overall body image. Body image was positively associated with both HRQoL indicators and predicted HRQoL in regression models. Exploratory mediation analysis was inconclusive: bootstrap confidence intervals suggested a possible indirect association between surgical approach and EQ-5D Index Values via body image, but the corresponding z-based test was not statistically significant.

Conclusions

In younger adults after cardiac surgery, minimally invasive access was associated with more favorable perceptions of chest appearance, while overall HRQoL was similar across groups. Body image was associated with HRQoL and may represent a relevant psychosocial factor to consider in postoperative care and shared decision making. Further prospective studies are needed to clarify its role.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s13019-026-04471-5.

Background

Cardiac surgery in younger and middle-aged adults is most commonly performed for valvular heart disease and coronary artery disease [1–3]. These conditions are potentially life-threatening and require surgical correction, which affects not only physical functioning but also psychological adjustment. Hospitalization and surgery are associated with increased anxiety, uncertainty and emotional distress, as patients must cope with both the physiological burden of treatment and changes in self-perception [4].

Traditionally, cardiac procedures are performed through a full median sternotomy, which provides excellent exposure but results in a prominent midline chest scar. Minimally invasive approaches, particularly for aortic and mitral valve surgery, have been increasingly introduced and offer comparable safety with potential advantages in recovery, including reduced pain, faster rehabilitation and lower risk of complications [5–7]. However, evidence regarding health-related quality of life (HRQoL) remains heterogeneous, and most studies have focused on clinical outcomes rather than on patients’ subjective experiences such as body image [7].

Scar visibility and location may be particularly important for younger patients, for whom physical appearance and social functioning are central to identity. Sternotomy scars are large and difficult to conceal, whereas minimally invasive scars are smaller and more laterally located. Previous research indicates that scar characteristics are closely related to body image and that dissatisfaction with postoperative appearance may persist beyond the acute recovery phase [8–10]. Changes in chest appearance may also influence self-esteem and perceived physical strength, even when clinical outcomes are favorable [9–11].

In addition to visible scarring, cardiac surgery may affect perceived physical competence and bodily integrity, which can further influence HRQoL [4, 7, 11]. Despite this, appearance- and identity-related aspects of recovery remain understudied in the context of different surgical approaches. In particular, it remains unclear whether younger patients undergoing minimally invasive versus sternotomy procedures differ in their body image and HRQoL, and whether body image may be associated with the relationship between surgical technique and patient-reported outcomes.

In the present study, we examined body image and HRQoL in adults under 60 years of age who had undergone cardiac surgery using either a minimally invasive approach or median sternotomy. We hypothesized that minimally invasive approaches would be associated with more positive body image and that better body image would be associated with higher HRQoL [8–11]. Additionally, we explored whether body image may be associated with the relationship between surgical approach and HRQoL.

Methods

Participants

The study included 47 adult patients (39 men, 83.0%; 8 women, 17.0%) who had undergone cardiac surgery within the past three years at the Cardiac Surgery Department of the University Clinical Center in Gdańsk, Poland. The mean age of the sample was 42.9 years (SD = 9.1), and the mean body mass index (BMI) was 27.2 kg/m² (SD = 4.7).

Eligibility criteria were: (1) age below 60 years, (2) completion of a cardiac procedure performed either through a minimally invasive approach or a median sternotomy, (3) an interval of at least four months since surgery to allow for wound healing and completion of early postoperative rehabilitation, and (4) absence of severe cognitive impairment or active psychiatric illness at the time of the study.

Patients were identified retrospectively from hospital records and contacted by telephone. All individuals received information about the purpose and scope of the study, the voluntary nature of participation, confidentiality of the data and their right to discontinue the interview at any time without consequences for their medical care. Verbal informed consent was obtained and documented for each participant, and data were anonymized before analysis. The study was conducted in accordance with institutional standards for non-interventional interview-based research and the principles of the Declaration of Helsinki.

The sample included patients after various valve and coronary procedures. In the minimally invasive group (n = 24), surgery comprised aortic valve replacement (AVR) and mitral valve procedures, that is mitral valve replacement (MVR) or mitral valve repair (MVP), performed mainly through right anterior thoracotomy (RAT) or a right axillary approach (TAX). In the sternotomy group (n = 23), procedures included coronary artery bypass grafting (CABG) as well as isolated and combined valve operations (AVR, MVR, MVP) and a small number of aortic aneurysm repairs with valve replacement.

Patients were identified retrospectively from hospital records as consecutive eligible cases and were contacted by telephone in chronological order of surgery. Overall, 79 eligible patients were approached, and 47 completed the structured interview and were included in the final sample. Thirty-two patients were not included because they either did not respond to the telephone contact or declined participation.

In our center, minimally invasive access is primarily offered for isolated aortic and mitral valve procedures in patients with suitable anatomy, whereas multivessel CABG and more complex combined procedures are usually performed via median sternotomy. Thus, the main clinical difference between the two groups lies in the underlying indication and index procedure rather than in a systematic tendency to reserve sternotomy for older or more clinically burdened patients. Choice of access route followed institutional practice and was based on standard clinical factors, including underlying pathology, coronary and valvular anatomy, expected need for concomitant procedures and surgeon expertise.

Table 1 summarizes the sociodemographic and clinical characteristics of the total sample and of the two surgical groups.

Table 1.

Sociodemographic and clinical characteristics of the sample by surgical approach

Variable	Total (N = 47)	Minimally invasive (N = 24)	Sternotomy (N = 23)
Age, years, mean ± SD	42.9 ± 9.1	45.2 ± 6.8	40.5 ± 10.6
Months since surgery, mean ± SD	11.0 ± 4.8	10.0 ± 4.8	12.0 ± 4.6
Height, cm, mean ± SD	177.7 ± 8.0	176.8 ± 7.2	178.8 ± 8.7
Weight, kg, mean ± SD	85.9 ± 15.4	83.0 ± 14.0	88.9 ± 16.6
BMI, kg/m², mean ± SD	27.2 ± 4.7	26.6 ± 4.7	27.8 ± 4.7
Men, n (%)	39 (83.0)	20 (83.3)	19 (82.6)
Women, n (%)	8 (17.0)	4 (16.7)	4 (17.4)
Surgical approach, n (%)
Minimally invasive	24 (51.1)	24 (100.0)	0
Sternotomy	23 (48.9)	0	23 (100.0)

Procedure

Data were collected using structured telephone interviews conducted by trained graduate students in psychology. Interviewers received dedicated training in patient communication, confidentiality procedures and the standardized administration of psychological questionnaires. Each interview lasted approximately 30–40 min and took place between 4 and 22 months after surgery, depending on the patient’s postoperative follow-up. By this time window, surgical wounds were expected to be fully healed and most patients to have completed basic cardiac rehabilitation, so their responses were more likely to reflect longer-term adjustment rather than acute post-surgical discomfort. This time window reflects a retrospective consecutive recruitment strategy, in which all eligible patients were approached in chronological order of surgery, and was necessary to achieve an adequate sample size in this relatively specific patient population. This relatively wide time window reflects real-world follow-up variability but may introduce heterogeneity; therefore, time since surgery was included as a covariate in statistical analyses.

Sociodemographic data (age, sex, body mass index [BMI], time since surgery) and clinical information (type of surgical approach) were obtained from medical records and used as covariates in the statistical analyses. Psychological measures were administered verbally during the interview, and patients’ responses were recorded directly into a secure research database.

Measures

Body esteem scale

Perception of body image was assessed using the Body Esteem Scale (BES) originally developed by Franzoi and Shields and adapted and normalized for the Polish population by Lipowska and Lipowski [13]. The scale consists of 35 items describing various body parts and bodily functions. Respondents indicate how they feel about each of them on a 5-point scale ranging from 1 (“strong negative feelings”) to 5 (“strong positive feelings”). For women, items are grouped into three subscales: Sexual Attractiveness, Weight Concern and Physical Condition. For men, the subscales are Physical Attractiveness, Upper Body Strength and Physical Condition. In the present study, subscale scores were calculated separately for men and women and then standardized within gender (z-scores). These gender-specific z-scores were averaged to form a single composite indicator of overall body image, referred to as the Body Image Score, with higher values indicating a more positive evaluation of one’s body. This approach was chosen to enable comparison across the full sample despite gender-specific subscale structures. However, it prioritizes comparability over domain-specific interpretation. To address this limitation, subscale-level analyses were also conducted as complementary exploratory analyses.

EQ-5D-5 L

Health-related quality of life was assessed with the EuroQol 5 Dimension 5 Level (EQ-5D-5 L) questionnaire [12]. The instrument comprises five domains: mobility, self-care, usual activities, pain or discomfort, and anxiety or depression. For each domain, respondents rate their current health on a 5-point scale (1 = no problems, 2 = slight problems, 3 = moderate problems, 4 = severe problems, 5 = extreme problems or inability), yielding a five-digit health state profile. An EQ-5D Index Value was derived from these profiles using Polish population tariffs, with higher scores indicating better health status. In addition, the EQ-VAS, a vertical visual analogue scale ranging from 0 (“worst imaginable health”) to 100 (“best imaginable health”), was used as a measure of self-rated overall health.

Both instruments have been widely used in interview-based formats, and in the present study items were read verbatim and response options repeated as needed to minimize administration bias.

Statistical analyses

All statistical analyses were performed using IBM SPSS Statistics, version 23 (IBM Corp., Armonk, NY, USA). Descriptive statistics (means, standard deviations, minima and maxima) were calculated for all variables. The distribution of continuous measures was examined using the Shapiro-Wilk test and visual inspection of histograms. Given the small sample size and significant deviations from normality for several variables, Mann-Whitney U tests were used to compare patients after minimally invasive surgery and those after sternotomy on body image and health-related quality of life indicators (Body Image Score, EQ-5D Index Value, EQ-VAS). Mann-Whitney U tests were also applied in exploratory analyses of the chest-specific body image item and selected Body Esteem subscales.

Associations between continuous variables (Body Image Score, EQ-5D Index Value, EQ-VAS, BMI, age and months since surgery) were examined using Pearson correlation coefficients. Despite moderate deviations from normality, Pearson correlations and linear regression models were retained because these procedures are considered robust to such violations in samples of this size, and inspection of residual plots did not indicate severe non-linearity or heteroscedasticity.

Multiple linear regression analyses were conducted to identify predictors of Body Image Score (surgical approach, BMI, age, months since surgery) and to examine the association of Body Image Score with each quality of life indicator (EQ-5D Index Value, EQ-VAS). For EQ-5D Index Value and EQ-VAS, models including Body Image Score alone were estimated first, followed by models additionally adjusting for BMI, age, months since surgery and surgical approach.

To examine whether body image mediates the association between surgical approach and health-related quality of life, we performed a simple mediation analysis in the SEM module of JASP (JASP Team, Amsterdam, The Netherlands). Surgical approach (minimally invasive vs. sternotomy) was entered as the predictor, Body Image Score as the mediator, and EQ-5D Index Value as the outcome. The EQ-5D Index Value was chosen as the primary HRQoL outcome for the mediation analysis because it is a preference-based summary score that reflects population health-state valuations, whereas the EQ-VAS was treated as a complementary, purely subjective rating. Indirect effects were examined using bias-corrected bootstrap confidence intervals based on 5,000 resamples and z-based tests. Because of the small sample size, cross-sectional design, and exploratory nature of this analysis, mediation findings were interpreted cautiously and were not considered confirmatory.

Given the exploratory nature of the chest-specific and subscale comparisons, no formal correction for multiple testing was applied. These analyses therefore increase the risk of type I error and should be interpreted as exploratory.

All tests were two-tailed; p < 0.05 was considered statistically significant, and p values between 0.05 and 0.10 were interpreted as non-significant but suggestive.

Results

Preparation of variables

The minimally invasive and sternotomy groups did not differ significantly in age (Mann–Whitney U = 218.0, p = 0.216) or time since surgery (U = 202.5, p = 0.117). Age was not significantly associated with Body Image Score in Pearson or Spearman correlation analyses.

Preparation of variables

The Body Esteem Scale (BES) included gender-specific subscales (three for men, three for women). To enable meaningful comparisons between sexes, each subscale was standardized within gender (z-scores), and then averaged into a single composite score representing overall body image perception (Body Image Score). This standardization procedure ensured comparability between male and female respondents while preserving individual variability.

Given our primary interest in overall body image rather than specific body domains, this composite Body Image Score was used as the main predictor and outcome-related variable, whereas subscales and the chest-specific item were examined in exploratory analyses.

Descriptive statistics

Table 2 presents the descriptive statistics for the main study variables by surgical approach.

Table 2.

Descriptive Statistics by Surgical Approach

Variable	Surgical Group	Mean	SD	Median	Min	Max
EQ-5D Index Value	Minimally Invasive	0.81	0.16	0.89	0.57	0.89
	Sternotomy	0.81	0.37	1.00	0.26	1.00
EQ-VAS	Minimally Invasive	75.00	17.32	80.00	50.00	90.00
	Sternotomy	80.00	16.33	80.00	60.00	100.00
Body Image Score	Minimally Invasive	0.21	0.28	0.20	-0.11	0.56
	Sternotomy	-0.21	1.46	0.00	-2.08	1.22

Higher Body Image Score, EQ-5D Index Value, and EQ-VAS values indicate more favorable outcomes

Tests of normality (Shapiro-Wilk) indicated significant deviations from the normal distribution for all variables (p < 0.05). Therefore, nonparametric tests were used for group comparisons.

Consistent with our center’s practice patterns, the minimally invasive group consisted predominantly of isolated valve procedures, whereas the sternotomy group was dominated by CABG with a minority of isolated or combined valve and aortic operations.

Comparison between surgical approaches

Group differences between patients after minimally invasive procedures (N = 24) and sternotomy (N = 23) were analyzed using the Mann-Whitney U test (Table 3). Effect sizes were calculated for Mann–Whitney tests using r = Z/√N. The effect size for Body Image Score was small to moderate (r = 0.27), whereas effect sizes for EQ-5D Index Value (r = 0.10) and EQ-VAS (r = 0.06) were small.

Table 3.

Comparison of Quality of Life and Body Image by Surgical Approach (Mann-Whitney Test)

Variable	Mean Rank (Minimally Invasive)	Mean Rank (Sternotomy)	U	Z	p	r
EQ-5D Index Value	25.31	22.63	244.50	-0.68	0.499	0.10
EQ-VAS	24.77	23.20	257.50	-0.40	0.690	0.06
Body Image Score	27.67	20.17	188.00	-1.87	0.061	0.27

Higher Body Image Score, EQ-5D Index Value, and EQ-VAS values indicate more favorable outcomes

Although the difference in Body Image Score did not reach statistical significance (p = 0.061), the effect size suggested a small-to-moderate difference between groups. Effect sizes were calculated as r = Z/√N and interpreted according to conventional thresholds as small (0.1), medium (0.3), and large (0.5).

Chest-specific and subscale analyses

To further characterize appearance-related differences between surgical approaches, we conducted exploratory analyses at the level of a chest-specific body image item and Body Esteem subscales.

In line with the clinical relevance of the chest region, we compared ratings of chest appearance between patients after minimally invasive surgery and those after sternotomy using the Mann-Whitney U test. A significant group difference emerged (U = 185.0, Z = -2.03, p = 0.043). In the minimally invasive group, most patients reported high satisfaction with their chest appearance, with 75.0% rating it as 4 or 5 on a 5-point scale and only 4.2% providing ratings of 2 or lower (Me = 4). In the sternotomy group, only 43.5% rated their chest as 4 or 5, whereas 21.7% gave ratings of 1 or 2 (Me = 3). This exploratory item-level finding indicates that patients’ ratings of chest appearance differed between surgical groups, although it should not be interpreted as a validated standalone outcome.

In men, exploratory analyses of the Body Esteem subscales using Mann-Whitney U tests showed a significant group difference for the upper body strength subscale (U = 109.0, Z = -2.28, p = 0.023), with higher scores in the minimally invasive group than in the sternotomy group. Differences in physical condition (U = 129.0, Z = -1.72, p = 0.086) and physical attractiveness (U = 144.5, Z = -1.28, p = 0.20) did not reach statistical significance, although physical condition showed a non-significant tendency in the same direction.

Predictors of body image

A multiple linear regression model with surgical approach, BMI, age and months since surgery as predictors of Body Image Score did not reach statistical significance (F(4,42) = 1.95, p = 0.12). A reduced model including only surgical approach and BMI showed a small but significant overall fit (F(2,44) = 3.49, p = 0.039, R² = 0.14), although neither predictor reached conventional significance when entered simultaneously (Table 4). In a simpler model with surgical approach as the sole predictor, patients who had undergone minimally invasive surgery reported a significantly more positive body image than those treated via sternotomy (B = -0.63, β = -0.32, p = 0.028).

Table 4.

Regression Model Predicting Body Image

Predictor	B	SE	β	t	p
Surgical Approach	-0.48	0.30	-0.25	-1.61	0.114
BMI	-0.05	0.03	-0.21	-1.43	0.161

Relationship between body image and quality of life

Pearson’s correlations indicated that body image was positively related to both quality-of-life measures (Table 5).

Table 5.

Correlation Matrix for Main Variables

Variable	EQ-5D Index Value	EQ-VAS	Body Image Score	BMI	Age	Months Since Surgery
EQ-5D Index Value	-	0.50***	0.39**	-0.23	0.20	0.07
EQ-VAS	0.50***	-	0.42**	-0.19	0.08	0.00
Body Image Score	0.39**	0.42**	-	-0.22	0.17	-0.13

**p < 0.01, ***p < 0.001

Higher Body Image Score values were moderately and positively associated with both EQ-5D Index Value and EQ-VAS scores.

Given deviations from normality, Spearman correlations were also examined and yielded consistent results in both direction and magnitude (Body Image Score with EQ-5D Index Value: ρ = 0.49, p < 0.001; with EQ-VAS: ρ = 0.49, p < 0.001). Spearman correlation coefficients are provided in Supplementary Table S1.

Regression models for quality of life

Body image was significantly associated with both HRQoL indicators in regression analyses. In simple models, body image predicted EQ-5D Index Value (F(1,45) = 8.28, p = 0.006, β = 0.39) and EQ-VAS (F(1,45) = 9.68, p = 0.003, β = 0.42).

In multiple regression models including surgical approach, age, BMI, and months since surgery, body image remained a significant predictor of EQ-5D Index Value (B = 0.11, β = 0.35, p = 0.022, 95% CI [0.02, 0.20]) and EQ-VAS (B = 7.66, β = 0.44, p = 0.006, 95% CI [2.31, 13.01]). None of the additional covariates reached statistical significance.

Mediation analysis

We then conducted an exploratory single-mediator SEM to examine whether Body Image Score was statistically consistent with an indirect association between surgical approach and EQ-5D Index Value, using bias-corrected bootstrap confidence intervals based on 5,000 resamples.

Patients treated with a minimally invasive approach reported more positive body image than those after sternotomy (B = -0.63, SE = 0.28, z = -2.25, p = 0.025, 95% CI [-1.18, -0.09]). In turn, more positive body image was associated with higher EQ-5D Index Values (B = 0.12, SE = 0.04, z = 2.88, p = 0.004, 95% CI [0.04, 0.20]). The direct effect of surgical approach on EQ-5D Index Value was small and non-significant (B = 0.03, SE = 0.10, z = 0.29, p = 0.78, 95% CI [-0.16, 0.22]).

The indirect effect of surgical approach on EQ-5D Index Value via Body Image Score was B = -0.08 (SE = 0.04, z = -1.81, p = 0.071). The bias-corrected 95% bootstrap confidence interval for the indirect effect did not include zero (-0.21 to -0.01). However, the corresponding z-based test was not statistically significant. The total effect of surgical approach on EQ-5D Index Value was also not significant (B = -0.05, SE = 0.09, z = -0.58, p = 0.56, 95% CI [-0.22, 0.12]). Therefore, the mediation analysis should be interpreted as exploratory and inconclusive.

Given the cross-sectional design, limited sample size, and potential confounding between surgical approach and procedure type, the mediation analysis was considered exploratory, hypothesis-generating, and inconclusive. No causal inferences were intended.

Discussion

In this study, we examined body image and health-related quality of life (HRQoL) between approximately four and 22 months after cardiac surgery in adults under 60 years of age treated either with minimally invasive approaches or median sternotomy. Overall HRQoL, measured with the EQ-5D Index Value and EQ-VAS, did not differ significantly between groups. The main finding was that patients after minimally invasive surgery reported more favorable body image, particularly in relation to chest appearance. In men, minimally invasive surgery was also associated with higher scores on the upper body strength subscale. Body image was positively associated with HRQoL in correlation and regression analyses. However, the exploratory mediation analysis was inconclusive and should not be interpreted as evidence of a psychological pathway.

These findings suggest that body image and generic HRQoL may capture different aspects of postoperative recovery. Previous studies have focused mainly on scar satisfaction and cosmetic outcomes [8–11]. The present study extends this literature by examining overall body image in relation to HRQoL in younger adults after cardiac surgery and by comparing minimally invasive and sternotomy approaches.

The chest-specific analysis provides a clinically intuitive illustration of this pattern. Patients in the minimally invasive group more often reported high satisfaction with the appearance of their chest than patients after sternotomy. However, this analysis was exploratory and based on a single Body Esteem Scale item; therefore, it should not be interpreted as a validated standalone outcome. Rather, it supports the broader observation that the location and visibility of the postoperative scar may be relevant to how younger patients evaluate their bodies after cardiac surgery [9–11].

A central limitation of this study is the confounding between surgical approach and procedure type. Minimally invasive access was used mainly for isolated aortic and mitral valve surgery, whereas the sternotomy group included predominantly CABG and more complex or combined procedures. We were unable to adjust statistically for procedure type because of the limited sample size and the substantial overlap between procedure type and surgical approach. Therefore, residual confounding by indication and procedure type cannot be excluded. In particular, valve surgery and CABG may differ not only in operative access but also in perceived disease trajectory, need for long-term secondary prevention, and expectations regarding recovery. The present findings should therefore not be interpreted as evidence that one surgical strategy is clinically superior to the other.

The wide follow-up interval, ranging from four to 22 months after surgery, is another important limitation. This interval was chosen to ensure that patients were beyond the acute postoperative phase, with healed wounds and completed early rehabilitation. Nevertheless, variability in time since surgery may have introduced heterogeneity. In additional analyses, time since surgery did not differ significantly between groups and was not associated with Body Image Score, but prospective designs with standardized follow-up points are needed to examine how body image and HRQoL change over time.

The predominance of men in the sample also limits interpretation. Although this reflects the epidemiology of cardiac disease in younger and middle-aged adults, the small number of women prevented meaningful sex-stratified analyses [14, 15]. This is particularly relevant because body image concerns may differ by sex and by scar location [16]. Future studies should include larger and more gender-balanced samples or deliberately oversample women to examine sex-specific patterns of postoperative body image and HRQoL.

Several additional limitations should be considered. The study was underpowered to detect small-to-moderate effects and was conducted in a single university center, which limits statistical precision and generalizability. We did not systematically record the characteristics of eligible patients who declined participation or did not respond to telephone contact; therefore, selection bias cannot be ruled out and may affect the generalizability of the findings. The cross-sectional and retrospective design prevents conclusions about causality or temporal direction. The study also relied on a generic HRQoL measure rather than a cardiac surgery-specific instrument, which may have reduced sensitivity to procedure-specific functional limitations. Finally, psychological data were collected by telephone, which may have limited the depth of discussion about sensitive appearance-related concerns.

The mediation analysis should be interpreted with particular caution. Although bootstrap confidence intervals were compatible with a possible indirect association, the corresponding z-based test was not statistically significant. Given the small sample size, cross-sectional design, and confounding between surgical approach and procedure type, this finding should be considered exploratory and inconclusive.

Despite these limitations, the study adds to the literature by highlighting body image as a relevant patient-reported outcome in younger adults after cardiac surgery. The findings suggest that postoperative evaluation should not be limited to survival, complications, and generic HRQoL, but may also include brief assessment of scar-related concerns, chest appearance, and perceived physical confidence. Future prospective, multicenter studies should include larger samples, baseline assessments, scar-specific measures, cardiac surgery-specific HRQoL instruments, and objective indicators of physical recovery.

Conclusions

In younger adults after cardiac surgery, minimally invasive approaches were associated with more favorable body image and chest appearance ratings than median sternotomy, while overall HRQoL was similar across groups. Body image was positively associated with HRQoL, but exploratory mediation findings were inconclusive. Because surgical approach was confounded with procedure type and the study was underpowered, these results should be interpreted cautiously and require confirmation in larger prospective studies. Routine follow-up and shared decision making in cardiac surgery may benefit from addressing appearance-related concerns and body image, particularly in younger patients.

Abbreviations

AVR

Aortic valve replacement

BES

Body Esteem Scale

BMI

Body mass index

CABG

Coronary artery bypass grafting

CAD

Coronary artery disease

EQ-5D-5L

EuroQol 5 Dimension 5 Level questionnaire

EQ-5D Index Value

index value derived from EQ-5D-5 L health state profiles

EQ-VAS

EuroQol visual analogue scale

HRQoL

Health-related quality of life

MVP

Mitral valve repair

MVR

Mitral valve replacement

QoL

Quality of life

RAT

Right anterior thoracotomy

TAX

Right axillary approach

Author contributions

AS conceived and designed the study, developed the study concept, performed the statistical analyses, interpreted the data, and drafted and revised the manuscript. ZK, JL and AM recruited participants and collected data during the structured telephone interviews. AK contributed to the study concept from a cardiac surgery perspective, supervised the clinical aspects of the project, and provided critical revision of the manuscript for important intellectual content. MB contributed to the interpretation of the findings in the context of cardiac surgery, critically revised the manuscript, and approved the final version. All authors read and approved the final manuscript.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not for profit sectors.

Data availability

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The study was conducted in accordance with institutional standards for non-interventional interview-based research at the Medical University of Gdańsk and with the principles of the Declaration of Helsinki. Patients were identified retrospectively from hospital records and contacted by telephone. All eligible individuals received information about the purpose and scope of the study, the voluntary nature of participation, confidentiality of the data, and their right to discontinue the interview at any time without consequences for their medical care. Verbal informed consent was obtained and documented for each participant, and all data were anonymized before analysis.

Consent for publication

No individual person identifiable data are included in this article. Therefore, consent for publication was not required.

Competing interests

The authors declare no competing interests.