Before the Incision, the Heart Already Knows: Why Preoperative Distress Matters?

All articles of this category (opens in new window) Letter to: Does Mental Distress Predict Cardiac Surgical Outcome? Thorac Cardiovasc Surg 2025; 73(07): 529-535 DOI: 10.1055/s-0042-1758824 10.1055/s-0042-1758824 I read with interest the article by Buschmann et al examining whether preoperative mental distress predicts early cardiac surgical outcomes.[ 1 ] The authors report a negative finding for short-term endpoints in their cohort. However, in a study currently under publication, we observed that patients presenting with pronounced preoperative anxiety or depressive symptoms tended to experience a more turbulent postoperative course, characterized by slower recovery and prolonged convalescence and more complications. These impressions are supported by multiple systematic reviews and meta-analyses showing that depression and anxiety around the time of cardiac surgery are associated with worse cardiovascular outcomes.[ 2 ] Biologically, the heart is not merely an end-pump organ of hemodynamics but a richly innervated organ with an intrinsic cardiac nervous system that communicates bidirectionally with the central nervous system. The “little brain” in the heart modulates autonomic tone, inflammation, and arrhythmogenic substrate, and may mediate how emotional states influence cardiac physiology.[ 2 ] [ 3 ] Across many cultural and philosophical traditions, the heart is viewed as a center of insight, wisdom, and decision-making. Cardiac efferent signals influence emotional processing, autonomic balance, and higher-order judgments, supporting the concept of a “thinking heart” or the intellectual heart whose responses shape how patients perceive stress and vulnerability before major surgery and affect quality of life postoperatively.[ 4 ] [ 5 ] [ 6 ] Investigators are encouraged to use validated, quantitative psychiatric measures at multiple perioperative time points and integrate biomarkers of inflammation and autonomic function to test mechanistic links. Clinically, systematic preoperative screening and early psychosocial interventions deserve evaluation as part of comprehensive cardiac surgical care. Contributor's Statement K.A. contributed to conceptualization, data curation, formal analysis, investigation, visualization, writing–original draft, writing–review and editing. Publication History Received: 16 December 2025 Accepted: 15 January 2026 Article published online: 28 January 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany