Minimally invasive aortic valve replacement (AVR) is increasingly used as an alternative to conventional AVR, despite limited randomized evidence available. To assess the evidence base, a systematic search identified 50 comparative studies with a total of 12,786 patients. A meta-analysis demonstrated that minimally invasive AVR is associated with reduced transfusion incidence, intensive care stay, hospitalization, and renal failure, and has a mortality rate that is comparable to conventional AVR. The evidence quality was mostly very low. Given the inadequate statistical power and heterogeneity of available studies, prospective randomized trials are needed to assess the benefits and risks of minimally invasive AVR approaches.