Classic Pages of the Journal of Extracorporeal Technology: Heater-Cooler Devices as a Conceivable Source of Infection.

Weitkemper et al. (1) concisely stated the 2002 issues surrounding the use of tap water in heater-cooler devices (the U.S. Food and Drug Administration [FDA] is using “HCDs”) in the operating room environment. They shared their method to handle the challenge of removing bacteria from the tap water in their heater-coolers and heat exchangers. This classic JECT article is profound reading within the context of nontuberculous Mycobacterium (NTM) epidemic we are experiencing today, worldwide with HCDs. Current estimates from case series publications suggest an approximate incidence rate of 4:10,000–1:1,000 cardiac surgical patients. In retrospect, it is significant that JECT published the only article to provide a warning until about 2013 when Mycobacterium chimera reports with cardiac surgery started to appear (2). Our classic authors write on page 277: “The infectious dose for an opportunistic pathogen is lower for immunocompromised subjects or those on antibiotic treatment. While connecting the HCU to oxygenator or blankets, it is impossible to avoid spilling water. This can contaminate the environment and place individuals at risk.” In 2015, Achermann et al. raised the red flag when they reported the aerosolization of M. chimera from HCDs in the operating room environment (3). Manufacturers of HCDs have worked rapidly and effectively to study and update the instructions for cleaning and disinfecting heatercoolers. Perfusionists around the world are responding rapidly to update their practice and disinfection protocols. Because of work by the manufacturers, perfusionists, and the FDA, our current state is much improved from the concerns expressed in our classic article on page 280 in 2002: “Unfortunately, there are no guidelines about proper disinfection of HCU systems, neither from HCU manufacturers nor oxygenator producers. Inconsistent statements about the use of disinfectants on one hand and a possible failure of a heat exchanger with a high risk of infection on the other shows that this problem has yet to be addressed.”