Abstract
Cardiac surgery imposes substantial physiological and psychological stress, with preoperative anxiety and postoperative pain persisting despite advances in perioperative care. Elevated anxiety has been associated with longer recovery and poorer outcomes, emphasizing the need for adjunctive, nonpharmacological interventions. Virtual reality (VR), an immersive digital technology that modulates sensory perception and emotional responses, has shown benefit in other surgical fields but has not been systematically evaluated in cardiac surgery. This systematic review and meta-analysis provide the first comprehensive synthesis of randomized controlled trials (RCTs) assessing VR in adult cardiac surgery. Following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 guidelines and International Prospective Register of Systematic Reviews (PROSPERO) registration, PubMed, Embase, and Cochrane Library were searched from inception to October 2025. Primary outcomes were anxiety, pain, and satisfaction; secondary outcomes included physiological responses, opioid use, and adverse events. Risk of bias was assessed using the RoB 2 tool, and evidence certainty was evaluated with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. The data were synthesized using a random-effects meta-analysis. Nine RCTs encompassing 888 participants were included. Meta-analysis of seven trials showed a nonsignificant trend toward lower preoperative anxiety with VR versus control (standardized mean difference (SMD) = -0.23; 95% CI -0.50 to 0.04, low heterogeneity (I² = 37%)). Four studies assessing patient satisfaction also showed a nonsignificant favor of VR (SMD = 0.36; 95% CI -0.65 to 1.38; I² = 92%). While two studies found no consistent analgesic benefit, physiological data suggested VR may attenuate autonomic arousal, lowering heart rate and blood pressure in select settings, though findings remained heterogeneous. Across all trials, VR was well tolerated, with only mild, transient adverse events reported. VR represents a feasible and safe perioperative adjunct in cardiac surgery, demonstrating favorable, nonsignificant trends in anxiety reduction and patient satisfaction. Further large-scale, standardized RCTs are warranted to confirm its physiological and clinical utility.