A patient with primary hyperaldosteronism undergoes adrenal vein sampling (AVS). The aldosterone-to-cortisol ratio from the right adrenal vein is 8× that of the left. The most appropriate next step is:

• A Bilateral adrenalectomy
• B Right laparoscopic adrenalectomy ✓
• C Lifelong spironolactone therapy
• D CT-guided percutaneous ablation of right adrenal gland

Explanation

AVS is the gold standard to lateralise aldosterone-producing adenoma (Conn's syndrome). A lateralisation ratio ≥4:1 confirms unilateral excess; unilateral laparoscopic adrenalectomy is curative in >90% of cases with resolution of hypokalaemia and improvement in hypertension. Bilateral adrenalectomy is performed only for bilateral hyperplasia confirmed on AVS. Spironolactone is appropriate when surgery is not possible or disease is bilateral.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.