Surgical management of recurrent MRSA empyema with eloesser flap in a complex thoracic patient: lessons from endobronchial valve failure

Endobronchial valves (EBVs) have emerged as a minimally invasive option for managing bronchopleural fistula (BPF), with reported efficacy rates of approximately 70–75%. However, their long-term performance in the setting of chronic infection remains poorly characterized, and documentation of specific failure mechanisms is limited. A 74-year-old man with recurrent methicillin-resistant Staphylococcus aureus (MRSA) empyema following right lower lobectomy presented with treatment failure 14 months after Zephyr EBV placement. During Eloesser flap creation, both valves were found displaced from the bronchial stump, with one completely dislodged into the pleural space. The bronchial stump showed evidence of erosion from chronic infection. The patient demonstrated clinical improvement following the Eloesser procedure, with negative cultures at three-month follow-up. This case provides direct intraoperative visualization of EBV displacement in chronic empyema, suggesting that ongoing infection, tissue destruction, and mechanical forces may compromise valve stability over time. The finding supports consideration of patient selection criteria for EBV therapy and demonstrates the continued role of open drainage procedures when minimally invasive approaches fail.