What is the best criterion for the interpretation of adrenal vein sample results in patients with primary hyperaldosteronism?

BACKGROUND: In patients with primary hyperaldosteronism, adrenal vein sampling (AVS) has emerged as a gold standard for distinguishing between unilateral and bilateral disease, but multiple criteria have been used and no consensus exists as to the most accurate criterion. The objective of this study was to determine which AVS criteria most accurately identify patients with unilateral surgical disease and are associated with significant clinical improvement after adrenalectomy.
METHODS: This is a retrospective analysis of AVS results in 108 patients with primary hyperaldosteronism treated at a single institution. Literature review of AVS criteria was used to distinguish between unilateral and bilateral disease.
RESULTS: Of the 10 AVS criteria identified in the literature, one criterion (ACTH stimulation, positioning: cortisol [adrenal]/cortisol [periphery] [Ca/Cp] > 5.0 and lateralization: aldosterone/cortisol [A/C] [dominant {D}]: A/C [nondominant {ND}] > 4:1) was the most accurate in identifying and correctly predicting lateralization of disease (P value range: < 0.001-0.0369). For this criterion, the true positive rate was 88%. The second most accurate criterion was no ACTH stimulation, positioning Ca/Cp > 1.1 and lateralization: A/C (D): A/C (ND) > 2:1. For this criterion, the overall true positive was 85%. However, we found no significant difference in clinical outcome based on individual criteria fulfillment.
CONCLUSIONS: Of the multiple criteria used for AVS evaluation, one criterion has the best accuracy. With the increasing use of AVS, there should be a consensus by which these results are evaluated and surgeons recommend adrenalectomy.