Virtual Reality for Pain and Anxiety Management in Cardiac Surgery and Interventional Cardiology

Pain and anxiety are common in patients undergoing cardiac surgery and percutaneous cardiac interventions. Virtual reality (VR) is an emerging non-pharmacological tool for pain and anxiety management. However, its application around cardiac procedures remains relatively unexplored. In this review, we perform a targeted non-systematic literature review to assess the current state-of-the-art of VR for pain and anxiety management in patients undergoing cardiac procedures. Contexts of interest were preprocedural, periprocedural, and postprocedural applications. Existing trials show inconsistent results. The majority of studies in the preprocedural (7 studies, n = 302), periprocedural (1 study, n = 99), and postprocedural stage (4 studies, n = 214) demonstrate significant reduction of pain and anxiety through VR distraction therapy or VR patient education. However, larger-scale trials (2 preprocedural studies [n = 233], 1 periprocedural study [n = 32], 2 postprocedural studies [n = 300]) report no effect. Current literature on effectiveness of VR for pain and anxiety management in cardiac surgery and interventional cardiology remains inconclusive.

associated with these medications include respiratory depression, renal dysfunction, gastrointestinal bleeding, sedation, nausea, vomiting, and constipation. 15,16Consequently, there is a growing need for nonpharmacological interventions to address pain and anxiety in order to mitigate the shortcomings and risks associated with this traditional approach.
Virtual reality (VR) is a modern emerging technique that offers the ability to provide an immersive digital simulation experience.This technology can be effectively utilized for 2 main purposes when it comes to pain and anxiety management: distraction therapy (Figure 1) and patient education (Figure 2).Distraction therapy is accomplished in the form of immersive 3-dimensional (3D) videos, calming music, and breathing exercises. 17,18By incorporating immersive visual and auditory stimuli, VR creates a captivating and serene environment that effectively diverts patients' attention away from the anxiety-inducing aspects of the procedure.This technique can be applied in preprocedural, periprocedural, and postprocedural phase of care.For patient education purposes, VR allows patients to embark on immersive 360 virtual tours that provide a comprehensive representation of their entire awaiting care process or a visual representation of their concerning disease and treatment. 19nce this technique aims on education about the awaiting procedure, this is only applied in the preprocedural stage.[22] The objective of this review is to comprehensively Articles were included if deemed relevant and/or had content related to the aforementioned key words.
After the final selection of included articles, a risk of bias assessment (Figure 3) was performed using the Cochrane Risk of Bias Tool. 23Below, and in

HIGHLIGHTS
Virtual reality is an emerging nonpharmacological tool for pain and anxiety management.
Literature on the potential of virtual reality in cardiovascular medicine is scarce.
Efficacy of virtual reality for pain and anxiety in cardiac interventions remains inconclusive.
Future research requires larger sample sizes and standardized outcome measures.el Mathari et al Virtual Reality for Pain and Anxiety Management Trait Anxiety Inventory (STAI) questionnaire, 42 which demonstrated notable improvements in the intervention group.Specifically, the intervention group showed significant enhancements in feeling calm (P ¼ 0.048) and experienced significant reductions in stress (P ¼ 0.001).
The second RCT in this domain assessed the impact of preprocedural VR patient education on anxiety. 31is study included 99 subjects undergoing cardiac surgery, who were randomly distributed in 3 groups:   This can include both a realistic simulation of the practice (A) and a virtual animation depicting the upcoming treatment (B).
el Mathari et al Virtual Reality for Pain and Anxiety Management  el Mathari et al Virtual Reality for Pain and Anxiety Management of preprocedural VR distraction therapy in reducing anxiety. 27  el Mathari et al Virtual Reality for Pain and Anxiety Management alongside conscious sedation or local/regional anesthesia during invasive procedures. 44However, in case of cardiac surgery, patients are typically placed under general anesthesia, which renders them unconscious and unresponsive to external stimuli, including VR.Consequently, the periprocedural use of VR applications in these patients is not feasible.showed that both groups experienced a reduction in anxiety after 3 days.However, this reduction was significantly greater in the intervention group compared to the control group (STAI score reduction À4.89 vs À2.72, P # 0.05).
This same inconsistency persists in the periprocedural assessment of VR distraction therapy for pain and anxiety during TAVR and AF ablation procedures.
One RCT (n ¼ 32) reported no significant effect on pain, 32 while another RCT (n ¼ 99) demonstrated a significant reduction of periprocedural pain. 33The latter is further supported by the reported case series showing beneficial effects of periprocedural VR distraction therapy in individual patients during cardiac catheterization (n ¼ 3) and pericardiocentesis (n ¼ 1). 34,35e postprocedural stage presents a significant opportunity to apply VR distraction therapy for pain and anxiety reduction.However, in this context as well, the existing literature presents conflicting results.While the majority of trials (4 studies with a total number of 214 subjects) report a significant reduction in postprocedural pain and anxiety with VR distraction therapy, [36][37][38][39] 2 larger-scale trials (shared total of 300 subjects) show no significant difference compared to conventional treatment. 40,41 is important to acknowledge the variability in these reported findings throughout all stages of cardiac care.We acknowledge that the narrative nature of this review is a limitation.While a thorough and comprehensive literature review was conducted, it is important to note that it was not a systematic literature review.This is primarily due to the scarcity of available data on this topic, which hinders the feasibility of conducting a comprehensive systematic Virtual Reality for Pain and Anxiety Management examine and elucidate the current and potential impact of VR technology in specifically reducing pain and anxiety across the preprocedural, periprocedural, and postprocedural phases of cardiac surgery and percutaneous cardiac interventions.By thoroughly evaluating and summarizing the existing literature on the application of VR distraction therapy for pain and anxiety management in the cardiovascular field, we aim to add a detailed novel overview to the literature on the concrete potential benefits and limitations associated with the implementation of VR distraction therapy for this specific purpose.In this review, we performed a targeted nonsystematic literature review within the electronic Medline (PubMed) and Google Scholar databases to identify the current state-of-the-art of VR for pain and anxiety management in cardiac surgery and percutaneous cardiac interventions.Contexts of interest were preprocedural, periprocedural, and postprocedural applications.Key search words included: VR, cardiac surgery, percutaneous cardiac interventions, preprocedural, periprocedural and postprocedural, pain management and anxiety management.Additionally, reference lists of all included articles were searched for additional relevant articles.

Virtual
Reality for Pain and Anxiety Management measure of the outcome.The results indicated higher levels of anxiety in the control group compared to the intervention group (STAI score 45 AE 11 vs 38 AE 7, P ¼ 0.02).A week prior to their procedure, the STAI questionnaire was administered again, revealing increased anxiety levels in the control group, while anxiety levels in the intervention group remained unchanged.These findings not only highlight the immediate impact of the different patient education options on preoperative anxiety but also underscore the distinction in long-term effects between the 2 groups.Another study assessed the same effect on patients undergoing cardiac catheterization. 26Sixty-four patients were randomly assigned to either receive conventional preprocedural care or additional VR patient education.Anxiety levels, procedural knowledge, and satisfaction were evaluated using custom-made questionnaires.The results revealed that patients in the intervention group experienced a significantly greater reduction in anxiety levels from baseline to postprocedure compared to the control group (D-5.1 vs D-4.0, P ¼ 0.03).Additionally, the intervention group demonstrated higher overall satisfaction scores (9.35 vs 8.97, P ¼ 0.04) and a better understanding of the procedure (3.88 vs 3.23, P < 0.01).A smaller feasibility study in the same population confirmed these results. 19A group of 8 patients underwent a virtual tour, providing them with an immersive view of their upcoming cardiac catheterization.Outcomes were assessed using the Presence questionnaire (mean 129.1 AE 13.4), System Usability Scale score (mean 89.1 AE 12), and Client Satisfaction questionnaire (mean 27.1 AE 3.2).All participants reported feeling notably less anxious about the impending procedure after experiencing the immersive VR education program.The same results were reported in a study with 33 patients undergoing atrial fibrillation (AF) ablation. 28Twenty-two patients were allocated to the control group and 11 patients to the VR patient education group.Here again, anxiety was measured by means of custom-made questionnaires.Results reported significant lower preprocedural anxiety scores in the VR patient education group compared to the control group (5.0 vs 7.1, P < 0.05).Surprisingly, a relatively large RCT that was published recently did not find a significant effect of VR patient education when compared to conventional education.29This study included 134 patients undergoing AF ablation who were equally distributed among a control and VR patient education group.The assessed primary outcome measure was anxiety, by

FIGURE 2
FIGURE 2 Virtual Reality Education Therapy Involves Creating a Virtual Representation of the Entire Care Process That Patients Will Undergo

F
E B R U A R Y 2 0 2 4 : 1 0 0 8 1 4 use of the Amsterdam Preoperative Anxiety and Information Scale (APAIS). 43This outcome measure did not differ between the 2 groups (10 [SD 8-13] vs 10 [SD 7-12], P ¼ 0.402).Subjects additionally filled in a questionnaire about worries on the procedure, which demonstrated that the intervention group had a significantly lower percentage of patients worrying about the ablation procedure compared to the control group (19.1% vs 40.9%,P ¼ 0.006).Nonetheless, it is important to note that this was a nonvalidated questionnaire.VR distraction therapy, on its turn, showed more consistent beneficial effects.An RCT with 60 patients undergoing coronary angiography studied the effect

FIGURE 3
FIGURE 3 Risk of Bias Assessment of All Included Studies Using the Cochrane Risk of Bias Tool

INTERVENTIONAL CARDIOLOGY. Only 2 Virtual
studies have reported about the periprocedural application of VR in interventional cardiology.The first study examined the impact of VR distraction therapy on pain and anxiety during transcatheter aortic valve replacement (TAVR) procedures.32The study involved a sample size of 32 participants.The intervention group (n ¼ 16) underwent VR distraction therapy during the TAVR procedure utilizing a headmounted device, while the control group (n ¼ 16) received conventional treatment.All patients underwent conscious sedation during the intervention.Primary outcomes were periprocedural anxiety and pain, both assessed with the VAS score.The intervention group demonstrated significantly lower levels of periprocedural anxiety (2 [IQR: 0-3.75] vs 5 [IQR: 2-8]; P ¼ 0.04).However, there was no significant difference in periprocedural pain levels between both groups (4 [IQR: 3-4.8] vs 4 [IQR: 2-6], P ¼ 0.61).A similar RCT was conducted involving 99 subjects undergoing AF ablation. 33Forty-eight patients received VR distraction therapy during the procedure, while 51 were treated conventionally.Periprocedural pain was assessed as the primary outcome using the VAS score.Results showed significantly lower periprocedural pain experience in patients who received VR distraction therapy compared to those who were treated conventionally (3.5 AE 1.5 vs 4.3 AE 1.6; P ¼ 0.004).Additionally, a case report and a case series (n ¼ 3) documented the periprocedural utilization of VR distraction therapy for pain and anxiety management during, respectively, emergency pericardiocentesis and diagnostic cardiac catheterization. 34,35In both contexts, the patients received VR distraction therapy throughout the procedures.Subsequently, all CENTRAL ILLUSTRATION Virtual Reality for Pain and Anxiety Management in Cardiac Surgery and Interventional Cardiology el Mathari S, et al.JACC Adv.2024;3(2):100814.J A C C : A D V A N C E S , V O L . 3 , N O . 2 Reality for Pain and Anxiety Management patients reported feeling comfortable and experiencing minimal pain during the procedure, attributing it to the distraction provided by the VR experience.POSTPROCEDURAL CARDIAC SURGERY.Several studies have examined the impact of postprocedural VR distraction therapy in cardiac surgery patients.An observational study involving 67 subjects described the use of VR distraction therapy to reduce pain after cardiac surgery on the intensive care unit (ICU).36All patients received a 30-minute session of VR distraction therapy on the first day following surgery in the ICU.The primary outcome measure was pain, which was assessed using a custom-made Likert scale.Results showed that 88% of the patients reported a decrease in pain levels (mean D-3.75) after the VR intervention.Another study by the same research group supported these results in a smaller group of patients (n ¼ 22).37 Patients received the same aforementioned VR intervention during their ICU stay following cardiac surgery and pain was assessed using a custom-made Likert scale survey.Among 22 patients, 21 reported experiencing a decrease in pain levels after undergoing the 30-minute VR intervention.An RCT conducted in the same setting with 100 subjects, yielded contrasting results.41This study assessed the impact of postprocedural VR distraction therapy on pain and anxiety in the ICU.The study design consisted of a control group and 3 intervention arms, which received different treatments: 1) VR distraction therapy; 2) VR distraction therapy with hypnotic audio; and 3) hypnosis by audio.All groups underwent a 20-minute intervention session on the day before and the day after cardiac surgery.Pain and anxiety were evaluated as primary outcomes using a VAS scale.Results showed no significant differences in postprocedural pain and anxiety between all groups.Another RCT consisting of 200 subjects also showed no significant effect of VR distraction therapy on postprocedural pain after cardiac surgery in the ICU.40In this study, subjects were allocated to either a VR distraction therapy group (n ¼ 99) or a control group (n ¼ 101).The primary assessed outcome was postprocedural pain by use of the analgesia/nociception index45 and the numeric rate scale (NRS).Results demonstrated no significant differences between the 2 groups in terms of both the analgesia/nociception index score and the NRS score.Lastly, another RCT was performed in the clinical ward with 60 subjects, evaluating the use of VR distraction therapy for clinical rehabilitation, including pain, after cardiac surgery.38Subjects were equally divided between a control group and intervention group.The VR intervention consisted of immersive exercises such as distractive breathing techniques and physical activity.Primary outcomes were measured using the Nottingham Health Profile questionnaire,46 assessing patients' incapacity across various domains, including pain levels.Results showed no significant difference in pain scores between the groups in the first 2 days.However, after 3 days, there was a significant decrease in pain score among patients in the VR group compared to the controls (P < 0.05).Subsequently, patients who received the VR intervention had also a shorter hospital stay compared to those in the control group (9.4 AE 0.5 days vs 12.2 AE 0.9 days, P < 0.05).INTERVENTIONAL CARDIOLOGY.In the field of interventional cardiology, there is a single study reporting the effect of postprocedural VR distraction therapy.This study assessed the impact of VR distraction therapy on postprocedural anxiety in patients after percutaneous cardiac angioplasty.39Sixtyfive patients were included and divided among a control (n ¼ 33) and intervention group (n ¼ 32).The intervention group received 6 sessions of VR distraction therapy during the first 3 days of the postprocedural stage.Each VR session lasted for 20 minutes.The primary outcomes for anxiety were measured using the STAI questionnaire.Results

4 Virtual
Consequently, these factors may have a negative impact on clinical outcomes.Hence, it becomes imperative to provide optimal management for pain and anxiety in this specific patient population.This paper explores the potential of VR as a nonpharmacological tool to reduce pain and anxiety among cardiac patients before, during, and after surgical and percutaneous cardiovascular interventions (Central Illustration).Trials evaluating the use of VR in preprocedural settings for cardiac surgery and interventional el Mathari et al J A C C : A D V A N C E S , V O L . 3 , N O . 2 , 2 0 2 Reality for Pain and Anxiety Management F E B R U A R Y 2 0 2 4 : 1 0 0 8 1 4 cardiology show inconsistent results regarding the effects on pain and anxiety.While the majority of trials (7 studies with a total number of 302 subjects) outcomes.Pain and anxiety are a complex phenomenon influenced by biological, social, and psychological factors, and their manifestation can vary among individuals.Therefore, incorporating objective measures such as heart rate variability and changes in blood pressure would provide a more comprehensive evaluation of the impact of VR on pain and anxiety.By structurally considering these recommendations, future studies can provide a more robust understanding of the effectiveness of VR in managing pain and anxiety in cardiac procedures.Moreover, the cost-effectiveness of utilizing VR for pain and anxiety management must be carefully assessed.This evaluation encompasses not only the expenses associated with software and hardware but also the time commitment required for integrating VR devices into daily clinical practices.Given that nurses are already engaged in essential clinical duties, introducing additional staff for the implementation of VR devices would incur additional costs.While other medical fields have demonstrated economic benefits of VR, 48,49 including reduced average costs per quality-adjusted life year through shorter hospitalization, decreased medication usage, and lower risk of clinical readmission, the cardiovascular field has yet to assess these factors.Conducting cost-effectiveness analyses specific to cardiac procedures would provide valuable insights into the economic impact of implementing VR interventions.Such analyses can help health care providers and policymakers make informed decisions about the adoption and integration of VR technology into routine cardiac care, considering both its clinical efficacy and financial implications.

Virtual 4 Virtual
Reality for Pain and Anxiety Management reality distraction on reducing patients' anxiety before coronary angiography: a randomized clinical trial study.Egypt Heart J. 2021;73(1):98.28.Chang SL, Kuo MJ, Lin YJ, et al.Virtual realitybased preprocedural education increases preparedness and satisfaction of patients about the catheter ablation of atrial fibrillation.J Chin Med Assoc.2021;84(7):690-697.29.Hermans ANL, Betz K, Verhaert DVM, et al. 360 degrees virtual reality to improve patient education and reduce anxiety towards atrial fibrillation ablation.Europace.2023;25(3):855-862.30.Pouryousef F, Navidian A, Ghahdarijani OR, Yaghoubinia F. Comparing the effect of virtual reality and rhythmic breathing on the anxiety of el Mathari et al J A C C : A D V A N C E S , V O L . 3 , N O . 2 , 2 0 2 Reality for Pain and Anxiety Management F E B R U A R Y 2 0 2 4 : 1 0 0 8 1 4 49.Pot-Kolder R, Veling W, Geraets C, et al.Costeffectiveness of virtual reality cognitive behavioral therapy for psychosis: health-economic evaluation within a randomized controlled trial.J Med Internet Res.2020;22(5):e17098.KEY WORDS anxiety, cardiac surgery, interventional cardiology, pain, virtual reality J A C C : A D V A N C E S , V O L . 3 , N O . 2

Table 1
24e present a comprehensive overview of the articles that were included, focusing on the implementation of VR distraction or education therapy for reducing pain and anxiety in the preprocedural, periprocedural, and postprocedural contexts.24Thestudy involved random allocation of subjects into either a control group or an intervention group.The intervention group received VR distraction therapy at the preoperative ward on the day of surgery.Outcomes were assessed using the State-

It achieves this by immersing them in serene and calming virtual environments accompanied by soothing sounds.
Virtual Reality Distraction Therapy Is Accomplished by Guiding Patients' Attention Away From the Nociceptive and/or Stressful Stimuli Present in the Environment

TABLE 1
Overview of VR Studies for Pain and Anxiety Reduction in Cardiac Surgery and Interventional Cardiology by Means of VR Distraction RCT ¼ randomized controlled trial; VR ¼ virtual reality.