Outcomes of patients undergoing surgery for primary aldosteronism based on adrenal venous sampling and/or radiological lateralisation indicate a role for both modalities in case selection

Background: Adrenal venous sampling (AVS) is considered the gold standard for lateralisation of aldosterone production in patients with primary aldosteronism (PA). However, in some patients AVS is not technically successful and management may depend on radiological findings. Aim: To determine 1) the success rate of AVS and 2) the outcomes after surgery related to the lateralisation modality. Method: 156 patients were included who presented 2007–2017 with a confirmed diagnosis of PA. Success of AVS was defined by the Endocrine Society 2016. Outcome criteria were 1) systolic blood pressure <140/90 mmHg 2) serum potassium <3.8 mmol/l 3) serum aldosterone <140 pmol/l 4) 0–1 anti-hypertensives post-op or two medications fewer than pre-op. The cohort was divided into approximate tertiles based on the year of referral: 2007–2013, 2014–15 and 2016–17 Results: Success rate of AVS increased from 30% (2007–13) to 77% (2016–17) (P<0.001). 26 (16%) were of young age, had a solitary lesion and were referred for surgery (group I). 94 underwent AVS, of whom 39 (41%) had a unilateral source (group IIA); 12 (13%) had bilateral secretion (group IIB) and 43 (45%) had non-diagnostic AVS (group IIC). 41 of the total were treated medically (group III). 148/156 underwent imaging: unilateral adenoma (95, 64%) dominant nodule (28, 18%) or no lesion (25, 16%). 69 patients proceeded to surgery: 23/26 (88%) from group I, 28/39 (71%) of patients from group IIA and 18/43 (43%) from group IIC. Post-operatively: 57% of patients had BP<140 (30% preop) P=<0.01; 71% serum potassium <3.8 (14% preop) P=<0.01; serum aldosterone fell from 1050 to 254 pmol/l (P<0.01), the number of anti-hypertensives decreased to from 2.6 to 0.9 post-operatively. Interestingly, there were no statistically significant differences between groups I, IIA and IIC in meeting successful outcome as defined by the ES Guidelines: these were met in 50% of those in group I, 41% of group IIA and 53% of those in IIC. Conclusions: Increased experience and technical refinement led to an significant increase in success rates of AVS. Patients treated with surgery had good clinical outcomes. However, we found equivalent success rates between those patients with lateralisation from AVS or radiology. This suggests that in patients where AVS is inconclusive or non-diagnostic, a proportion of patients will still improve with surgery.