Q&A: Can virtual reality experiences calm patients’ nerves going into open-heart surgery?
Key takeaways:
- Virtual reality helped calm patients’ nerves before cardiac surgery.
- Holistic anxiety reduction may be preferable to perioperative anxiolytic drugs.
- Future VR experiences may be personalized using generative AI.
A preoperative virtual reality experience helped to calm anxiety and reduce pulse rate for older patients undergoing cardiac surgery, researchers at Mayo Clinic reported.
Perioperative use of anxiolytic drugs during surgical procedures was associated with perioperative respiratory events and may complicate intubation and extubation, which means holistic approaches to patient anxiety reduction before cardiac surgery may be preferred, according to a study published in Mayo Clinic Proceedings.
To test this hypothesis, Jordan D. Miller, PhD, associate professor, cardiovascular disease researcher and co-vice chair of basic science research in the department of cardiovascular surgery at Mayo Clinic, and colleagues designed a randomized controlled trial in which 100 patients undergoing first-time sternotomy for cardiac surgery were assigned to a VR headset or tablet intervention. Anxiety was assessed using a standardized questionnaire administered before and after surgery.
The researchers reported that patients assigned to the VR experience reported significantly reduced anxiety scores compared with baseline while those assigned to the tablet intervention did not. Pulse rate was also significantly reduced but was similar between the groups.
Healio spoke with Miller about the preoperative immersive VR experience, its impact on patient anxiety and how future iterations of the intervention may be expanded and individually tailored to each patient.
Healio: What motivated you to investigate this VR strategy to reduce preoperative anxiety in older patients undergoing open-heart surgery?
Miller: Much of what my research program focuses on is biology of age-associated CVD, and we do a lot of drug development, but we’re looking at issues that patients face from an overall holistic perspective. How can we optimize care for patients from the time of diagnosis, how do we develop innovative, early treatments that delay surgery, and if they need intervention, the surgical episode and recovery?
We met with our cardiac surgeons who had this substantive focus over the years on trying to reduce patient anxiety prior to surgery, which is strongly associated with preoperative anxiolytics that can make it more difficult to intubate patients, and also reducing postoperative anxiety, which is associated with increased pain medication use.
More than a decade ago, several of our cardiac surgeons had done studies looking at the impact of music therapy and massage therapy on postoperative anxiety, and showed it reduced anxiety, sensation of pain and pain medication use after surgery.
We asked if there are ways we can identify more scalable technologies that would help reduce anxiety, specifically testing it in a preoperative state. Patients typically come in early in the morning for their preoperative preparations, but ultimately sit in a room, often by themselves, and reflect on their upcoming procedure.
The hope was that simple interventions like this would reduce anxiety and ultimately improve patient experience.
Healio: What attempts have been made historically to reduce preoperative anxiety?
Miller: In terms of preoperative anxiety, there hasn’t been a lot. Standard of care here is if a patient makes a request for an anxiety-reducing medication, that request will be honored. Otherwise, there is not much done to actively manage anxiety.
While this technology has been rigorously tested in younger populations, but emerging technologies have not been tested much in older populations. Our study population was patients undergoing first-time sternotomy and the average age was approximately 60 years old.
Even patients without diagnosed clinically significant anxiety can still have an acutely heightened anxiety level that can be clinically significant. In many instances, people feel stigmatized if they say they are anxious or would like an anxiety-reducing medication.
This was a non-stigmatizing, relatively simple, very well-tolerated intervention that can tamp down anxiety levels and hopefully give them a better preoperative experience during a time normally spent reflecting.
Healio: Can you describe some of what a patient would experience with this VR intervention?
Miller: We used a relatively standardized intervention for this trial. The VR experience displayed a variety of nature scenes in which patients would search for a specific object in the virtual environment. Once they found the object and focused on it for a few seconds, the environment would change to the next of the four seasons.
That combination of an immersive experience helping patients to remove themselves from a stressful environment, and the active engagement with that virtual environment, helped us demonstrate the clinical meaningfulness of anxiety reduction with VR.
Healio: How specifically did you measure changes in anxiety levels? Did you measure postoperative benefit?
Miller: In terms of measuring anxiety levels, we used the State-Trait Anxiety Inventory, which is a series of questions administered pre- and postintervention. It is a well-validated and standardized test for assessing anxiety.
We used devices to measure heart rate, BP and respiratory rate to get some feeling for not only subjectively measuring anxiety, but also to assess whether there is some physiologic evidence of reductions in anxiety.
What we saw was a unique “anxiety fingerprint” with the State-Trait Anxiety Inventory being reduced with either the tablet intervention or VR treatment, in addition to small but significant reductions in pulse rate, consistent with a patient being more relaxed.
So far, our focus has been on evaluating this preoperative state. We have not looked at whether this is impacting outcomes or having other clinical benefit postoperatively.
As we are looking to next steps, we are trying to explore different ways in which we might be able to implement this technology in a more sustained way, and perhaps in a more frequent or accessible way, giving patients on-demand access to the technology during postoperative phases where anxiety can be high.
We know patients want to minimize postoperative pain medication use, and many have concerns about use of opioids to manage pain. The best approach would be to have on-demand access to the VR technology and see whether it influences their clinical trajectory and pain medications, but that is beyond the scope of what we investigated here.
Healio: Did you notice any differences in anxiety scores between patients who used the tablet compared with the VR headset?
Miller: We did not see a statistically significant difference between the two groups. It is fair to say in the VR group there was a significant reduction, and that change was more consistent compared with what we saw in the tablet group. The tablet group had a trend toward a decrease, but did not reach statistical significance.
From that perspective, we cannot say the immersive experience was superior, but we can say it was the only intervention that resulted in a statistically significant reduction in anxiety.
Healio: Do you believe a similar intervention could benefit patients undergoing other kinds of planned surgeries?
Miller: I do. As we are looking at how we can we help patients understand what is going to happen during their procedure, reductions in anxiety can have a positive influence across multiple domains.
We know if patients are anxious and have high level of anxiety, their likelihood to absorb all the information being presented to them during a preoperative consult is dramatically reduced. Evaluation across a broader range of interventions to reduce stress and anxiety in patients’ lives may lay a better foundation for them heading into a procedure more prepared and, ideally, have better outcomes, less pain medication use and a more positive outlook after the procedure.
Healio: Is there anything else that you would like to say about this trial?
Miller: It is an exciting time for these technologies. We had a standardized intervention, but the company we collaborated with on this, Healium, is actively developing more generative AI-based immersive experiences. It is difficult to have an infinite number of interventions or virtual environments pre-created for patients. With generative AI-based imagery, it gives us the opportunity to expose patients to an immersive technology we know could reduce anxiety and personalize and tailor the environments to ones more relaxing for each individual patient. That is the endgame: meeting patients where they are with individualized, tailored interventions optimized for the best surgical experience.
Healio: The concept is to use generative AI to allow these patients to tailor their own stress-reducing environments in VR?
Miller: Absolutely. With the rapid rate at which technology is advancing, it is going to be a tremendously exciting time for physicians and innovators who want to identify unique interventions that never existed before.
References:
- Malloy T. Mayo Clinic researchers and surgeons test virtual reality to calm presurgery jitters. Mayo Clinic News Network. https://newsnetwork.mayoclinic.org/discussion/mayo-clinic-researchers-and-surgeons-test-virtual-reality-to-calm-presurgery-jitters/. Published Feb. 12, 2025. Accessed Feb. 17, 2025.
- Subramaniam T, et al. Mayo Clin Proc. 2025;doi:10.1016/j.mayocp.2024.08.027.
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