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arked improvement in energy levels. At device inter-ogation, the atrial threshold was 0.75 V at 0.4 msec, andmpedance was 537 ohms. Ventricular threshold was 0.75

at 0.4 msec and impedance was 224 ohms.

omment

ailure of pacing systems in children dependent onacing for survival can have devastating consequences.ailure can occur due to software-related issues (pro-ramming) or due to hardware issues (generator or

eads). For lead issues, lead replacement or repositionings commonly advocated as definitive treatment [3]. Withpicardial systems, this requires reoperative thoracot-my, with potential morbidity.Some mechanical lead problems can be managed less

nvasively. Insulation defects can be repaired using patchits [4]. Conductor fractures on the extrathoracic portionf unipolar leads can be managed with a new lead tiproximal to the fracture. Conductor fractures on bipolar

eads can sometimes be managed by reprogramming theenerator to the unipolar mode through the tip. Polarity

s programmable from bipolar to unipolar with currentystems, but the option of polarity reversal, which ex-hanges anode and cathode functions, is not currentlyvailable [5]. Some axial bipolar leads can be converted tounipolar lead by cutting back the anode to expose a

uitable length of the cathode with intact insulation.hen a bipolar lead has been fashioned by connecting

ndependent unipolar leads to a Y-adapter with set-crews, the good lead can be unscrewed from the adapternd connected directly to the generator.These options are not intuitive, and may not be appre-

iated, even by experienced physicians. For this patient,ecanalization of the superior vena cava to accommodateew transvenous leads was recommended. This ap-roach is infrequent, with insufficient experience to de-ne the related morbidity. Long-term anticoagulationould also be required due to increased risk of emboli

rom the endocardial lead.We recommended a simpler procedure, conservatively

stimating the probability of success at 50%, because weould not determine the electrical characteristics of thenode preoperatively. Intraoperatively, we tested thenipolar function of the anode by connecting one pacingire directly to the ring of the lead and the second to therounded skin retractor.If at least one functional conductor can be identified,

vailable connectors should allow the construction of aunctional lead. Lead fracture therefore does not alwaysequire lead replacement. Intrathoracic fractures, how-ver, cannot be repaired at present without a thoracot-my. For intrathoracic lead fractures with at least 1 cm of

ntact conductor to the lead button (Fig 1), we haveccasionally been able to restore function during thora-otomy by adding an extender to the button or screw-inip.

The specific lead repair described here has been reli-ble in our hands, with no failure in a small number (n �

) of cases. The patient described here was judged to have

Ct

2010 by The Society of Thoracic Surgeonsublished by Elsevier Inc

rhythm that would be adequate in the event of failure ofhe repaired lead. If she were totally pacemaker-dependent,er problem would likely have been managed more aggres-ively. Potential options for caval recanalization or repeathoracotomy, or both, remain available if and when they areeeded.

r Rusanov is supported by National Institutes of Health Train-ng Grant 5T32GM008464-17. Dr Spotnitz is the George H.

umphreys II, Professor of Surgery.

eferences

. Cohen MI, Bush DM, Vetter VL, et al. Permanent epicardialpacing in pediatric patients. Seventeen year of experienceand 1200 outpatient visits. Circulation 2001;103:2585–90.

. Johns JA, Fish FA, Burger JD, Hammon JW Jr. Steroid elutingepicardial pacing leads in pediatric patients: encouragingearly results. J Am Coll Cardiol 1992;20:395–401.

. Pavia S, Wilkoff B. The management of surgical complicationsof pacemaker and implantable crdioverter-defibrillators. CurrOpin Cardiol 2001;16:66–71.

. Mahaptra S, Homoud MK, Wang PJ, Estes NA 3rd, Link MS.Durability of repaired sensing leads equivalent to that of newleads in implantable cardioverter defibrillator patients withsensing abnormalities. Pacing Clin Electrophysiol 2003;26:2225–9.

. Jung W, Manz M, Luderitz B. Which programmable functionsof pacemakers are available, and what is their clinical rele-vance? Herz 1991;16:158–70.

ree Anterolateral Thighombined Flap for Chronicostpneumonectomy Empyema

un-Ta Tsai, MD, Chien-Chang Chen, MD,ung-I Lu, MD, Ming-Jang Hsieh, MD,ichelle Huang, MD, and Yur-Ren Kuo, MD, PhD

epartments of Plastic and Reconstructive Surgery andardiovascular and Thoracic Surgery, Chang Gung Memorialospital-Kaohsiung Medical Center, Chang Gung Universityollege of Medicine, Kaohsiung, Taiwan

anagement of postpneumonectomy empyema has alwayseen a challenging task. Local flaps or free muscle flaps areptions for recalcitrant cases when traditional therapeuticttempts fail. This report presents 2 patients with chronicostpneumonectomy empyema who were treated with annterolateral thigh combined flap consisting of vastus late-alis and rectus femoris muscles. This method showedromising results for reconstruction of large empyemaefect.

(Ann Thorac Surg 2010;90:651–4)© 2010 by The Society of Thoracic Surgeons

ccepted for publication Jan 6, 2010.

ddress correspondence to Dr Kuo, Department of Plastic and Recon-tructive Surgery, Chang Gung Memorial Hospital-Kaohsiung Medical

enter, 123, Ta-Pei Rd, Niao-Sung Hsiang, Kaohsiung, Taiwan; e-mail:

1207816@ms22.hinet.net; kuoyr@adm.cgmh.org.tw.

0003-4975/$36.00doi:10.1016/j.athoracsur.2010.01.074

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uccessful management of chronic postoperative empy-ema remains challenging. Surgical strategies include

dequate pleural drainage, closure of bronchopleural fis-ula, and obliteration of the residual pleural space [1–3]. For

large residual pleural space, a single muscle flap isometimes inadequate to obliterate the pleural cavity, re-ulting in recurrent empyema [4]. This report documents 2atients in whom the use of a free anterolateral thigh (ALT)ap consisting of vastus lateralis (VL) muscle and rectus

emoris (RF) muscle provided sufficient muscle volume forbliteration of a large pleural space.The ALT combined flap included 2 muscle components

VL and RF muscles) and a skin paddle that was used as aentinel flap to monitor the viability of the deeper muscle.he perforators supplying the skin paddle were located byoppler ultrasound examination [5]. The vascular pediclef the composite flap was the descending or transverseranch of the lateral circumflex femoral artery.The skin incision was initially made medially to the flap.

he anterior fascia was divided, and the RF and VL musclesere identified. The vascular pedicle was identified in the

ntermuscular septum between RF and VL and meticu-ously dissected. All other branches from the descendingrtery and some branches arising directly from the super-cial femoral artery entering the muscle distally could beivided. The combined flap was inserted into the empyemapace through the thoracotomy. The pedicle was anasto-osed to the thoracodorsal artery and accompanying vein.

ase Reports

atient 166-year-old man with a history of pulmonary aspergil-

oma underwent left pneumonectomy 4 years earlier thatas complicated by refractory empyema (Fig 1A). Resectionf the third rib and evacuation of the empyema resulted in400-mL pleural space defect. An ALT combined flap of VLnd RF muscles with a surface area of 28 � 18 cm2 wasarvested for insertion into the empyema space (Fig 1B). Toonitor viability of the muscles, we used a small skin

addle (12 � 5 cm2) supplied by the same perforator as theL (Fig. 1C). The vascular pedicle was then anastomosed to

he thoracodorsal vessels.The postoperative course of the patient was unevent-

ul. Chest roentgenogram performed 6 months laterhowed successful obliteration of pleural space defectnd no recurrence of empyema.

atient 270-year-old man with empyema, who had a history of

uberculosis and a destroyed left lung, was previouslyreated with tube thoracostomy, decortications, andébridement. A left-side pneumonectomy through the em-yema, with placement of latissimus dorsi and serratusnterior muscle flaps on the left main bronchial stump waserformed when other treatment attempts failed. A recur-ent empyema and a bronchopleural fistula later developed

Fig 2B). After evacuation of the empyema and closure of c

ig 1. (A) Preoperative chest roentgenogram reveals a large empyeman the left chest of a 66-year-old man with a history of pulmonary as-ergilloma who underwent left pneumonectomy. (B) An anterolateralhigh composite flap of vastus lateralis (VL) and rectus femoris (RF)uscles (surface area, 28 � 18 cm2) was used to obliterate a 400-mL

ead space. The flap pedicle was supplied by the lateral circumflex fem-ral artery (arrow). (C) Muscle viability was monitored with a 12- �-cm2 skin paddle (arrowhead), supplied by the perforator of the lateral

ircumflex femoral artery.

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653Ann Thorac Surg CASE REPORT TSAI ET AL2010;90:651–4 THIGH FLAP FOR POSTPNEUMONECTOMY EMPYEMA

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he fistula, an ALT combined flap of 26 � 16 cm2 wasarvested by techniques previously described (Fig 2A). Theap was then inserted into the empyema space, and theedicle of the descending branch of the lateral circumflex

emoral artery was anastomosed to the thoracodorsalessels.The postoperative course of the patient was unevent-

ul, but he experienced mild extension weakness of theeft donor thigh. At 3 months postoperatively, the chestoentgenogram and computed tomography showed com-lete obliteration of the residual pleural space; however,ild residual empyema recurred at 8 months (Fig 2C).

he patient recovered uneventfully after conservativereatment by temporary chest tube thoracostomy.

omment

uccessful management of postpneumonectomy empyemas a significant challenge for thoracic surgeons. For intrac-able cases, transposition of extrathoracic muscles (eg, pec-oralis major, latissimus dorsi, serratus anterior, and rectusbdominis) or thoracoplasty can be used to eliminate deadpace [6]. Microvascular free tissue transfer is the nextption if local muscles are not available [3]. Tsai andolleagues [2] described the successful use of free deepithe-ialized ALT myocutaneous flaps for the reconstruction ofhronic empyema [2]. However, a single muscle flap mayot be adequate for recurrent chronic empyema with a largeead space due to insufficient volume. Techniques such as aouble flap with vascular flow-through linkage or a two-flap

ransfer have been used for extensive composite defecteconstruction [7]; however, these reconstructions may re-uire multiple revisions to achieve acceptable outcome [4].For patients with postpneumonectomy empyema, a

ersatile free flap with a large volume would be the idealption for reconstruction. This report documents 2 pa-ients who underwent successful reconstruction with anLT combined flap of VL and RF muscles, without major

omplications. Chest computed tomography at 3 monthsostoperatively showed no intrathoracic dead space inither patient. Patient 2, however, sustained a smallecurrent pleural empyema at 8 months. Chest tubehoracostomy was temporary placed and his symptomsater subsided. It was highly suspected that the residualmpyema was due to gradual muscle atrophy of the ALTombined flap. This problem can be overcome by motorerve repair of the transferred muscle components or byollapse thoracoplasty at the time of muscle transfer toeduce residual dead space.

The VL and RF are the main components of the quadri-eps femoris muscle that acts as the prime extensor of thenee joint with a concentric contraction. As expected, bothatients exhibited mild knee extension weakness of theonor thigh. However, both patients could ambulate andesume daily activities without difficulty.

e acknowledge the contributions of Nicolae Ghetu, MD,Gr.T.Popa” University of Medicine, Lasi, Romania, for help

ig 2. (A) An anterolateral thigh (ALT) combined flap of vastus latera-is (VL) and rectus femoris (RF) muscles was designed for a 70-year-oldan with a history of tuberculosis who presented with recurrent empy-

ma after pneumonectomy, as demonstrated in the (B) the chest roent-enogram which shows a large cavity in the left chest. (C) Computedomography imaging after evacuation of the empyema and closure ofhe left main bronchus fistula revealed successful insertion of the com-ined flap (arrow) into the empyema space; however, mild residual em-

ith editing manuscript.

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654 CASE REPORT TALAL AHMED REDA MAHMOUD ET AL Ann Thorac SurgBISMUTH PASTE FOR EMPYEMA THORACIS 2010;90:654–5

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eferences

. Puskas JD, Mathisen DJ, Grillo HC, et al. Treatment strategiesfor bronchopleural fistula. J Thorac Cardiovasc Surg 1995;109:989–95.

. Tsai FC, Chen HC, Chen SH, et al. Free deepithelializedanterolateral thigh myocutaneous flaps for chronic intractableempyema with bronchopleural fistula. Ann Thorac Surg 2002;74:1038–42.

. Chen HC, Tang YB, Noordhoff MS, Chang CH. Microvascularfree muscle flaps for chronic empyema with bronchopleuralfistula when the major local muscles have been divided—onestage operation with primary wound closure. Ann Plast Surg1990;24:510–6.

. Huang WC, Chen HC, Wei FC, Cheng MH, Schnur DP.Chimeric flap in clinical use. Clin Plast Surg 2003;30:457–67.

. Kuo YR, Jeng SF, Kuo FM, Liu YT, Lai PW. The versatility offree anterolateral thigh flap for reconstruction of soft tissuedefects: a review of 140 cases. Ann Plast Surg 2002;48:161–6.

. Pairolero PC, Trastek VF. Surgical management of chronicempyema: the role of thoracoplasty. Ann Thorac Surg 1990;50:689–90.

. Koshima I, Yamamoto H, Hosoda M. Free combined compositeflaps using the lateral circumflex femoral system for repair ofmassive defects of the head and neck regions: an introduction tothe chimeric flap principle. Plast Reconstr Surg 1993;92:411–20.

ismuth Paste Injection formpyema Thoracis: A 100-Year-Oldethod Revisited

alal Ahmed Reda Mahmoud, PhD,or Izham Ismail, MD, Ahmad Sobri Muda, MMed,

nd Mohd Ramzisham Abdul Rahman, MS

ivision of Cardiothoracic Surgery and Department ofadiology, Heart and Lung Centre, Universiti Kebangsaanalaysia Medical Centre, Kuala Lumpur, Malaysia

ismuth paste injection into the pleural cavity used to betreatment for chronic empyema thoracis. This method,owever, was long forgotten and scarcely practiced due

o advanced surgical techniques and antibiotic therapy.e report a 50-year-old man with chronic empyema

horacis who was successfully treated with bismuth pastenjection after a failed surgical decortication and a long-erm chest drainage. This case highlights a trial of a00-year-old method of bismuth paste injection whichroved effective after standard measures had failed.

(Ann Thorac Surg 2010;90:654–5)© 2010 by The Society of Thoracic Surgeons

he management of chronic empyema thoracis hasalways been challenging. The treatment options

nclude chest tube drainage, surgical decortication, tho-acoplasty, and an open window thoracostomy [1, 2].wing to its multifactorial etiology and the complexity of

he disease, even in the present time there is still no

ccepted for publication Feb 15, 2010.

ddress correspondence to Dr Talal Ahmed Reda Mahmoud, 26-19-4

rima Midah Height condo, Jalan Midah 8A, Taman Midah, Cheras, 56000uala Lumpur, Malaysia; e-mail: treda2001@hotmail.com. s

2010 by The Society of Thoracic Surgeonsublished by Elsevier Inc

ingle ideal treatment or a gold standard practice that cane successfully applied to treat this condition.Even though the incidence of empyema thoracis has

educed remarkably with the advancement of antibioticherapy, the morbidity and mortality as a result of this istill high [1, 2]. On the other hand, performing an openindow thoracostomy results in a long hospital stay, andisfigurement of the chest wall after thoracoplasty is veryemoralizing to the patients. Historically, empyema tho-acis and suppurative sinuses were mainly treated withismuth paste injection into the affected cavity, withreat success [3]. We report a successful case of a bis-uth paste injection in a long-standing chronic empy-

ma thoracis that failed conservative treatment andurgery.

50-year-old man was referred for a right-sided chronicuberculous empyema thoracis. He initially underwent ahoracotomy and decortication, after which he wasreated with a long-term chest tube for more than 5 years,ithout success. A redo thoracotomy, decortication, pleu-

ectomy, and resection of the osteomyelitic fifth rib wereerformed. The lung failed to expand, however, and

here was a persistent cavity with pus collection (Fig 1).Four weeks postoperatively, he underwent a trial of a

ismuth paste injection, a method that was first practicedore than 100 years ago. His condition improved, and heas discharged well a week later. He remained asymp-

omatic at the 2-year follow-up.This procedure should only be initiated when the

ischarge from the nonhealing pleural cavity is minimal�50 mL/d). The bismuth paste (bismuth subnitrate io-oform paste, Zulat Pharmacy, Kuala Lumpur, Malaysia)as prepared by a mixture of bismuth subnitrate andaseline (white soft paraffin, Pharmaniaga, Selangor Da-

ul Ehsan, Malaysia) in 1:9 ratio, with the latter acting assolvent resulting in a semisolid preparation, and sub-

equently heated to allow liquefaction. The amount re-

ig 1. A computed tomography image of the thorax before the bis-uth injection shows the nonhealing cavity in the right pleural

pace.

0003-4975/$36.00doi:10.1016/j.athoracsur.2010.02.031