Contralateral suppression in adrenal venous sampling predicts clinical and biochemical outcome in primary aldosteronism

CONTEXT

The role for hormone parameters at adrenal venous sampling (AVS) in predicting clinical and biochemical outcome remains controversial.

OBJECTIVE

To investigate the impact of hormone parameters at AVS under cosyntropin stimulation on lateralization and on complete biochemical and clinical outcome.

METHODS

We retrospectively evaluated 150 sequential AVS under cosyntropin infusion. Bilateral successful cannulation rate was 83.3% (n = 140), 47.9% bilateral and 52.1% unilateral. The lateralization index (LI), aldosterone/cortisol ratio (A/C) in the dominant adrenal vein (AV), relative aldosterone secretion index (RASI = A/C in AV divided by A/C in inferior vena cava) were assessed. The contralateral suppression (CS) percentage was defined by (1 - nondominant RASI) *100.

RESULTS

A nondominant RASI <0.5 (CS >50%) had 86.84% sensitivity and 92.96% specificity to predict contralateral lateralization. An A/C ratio in dominant AV >5.9 (74.67% sensitivity and 80% specificity) and dominant RASI >4.7 (35.21% sensitivity and 88.06% specificity) had a worst performance to predict ipsilateral lateralization. Complete biochemical and clinical cure were significantly more frequent in the patients with CS >50% [98.41% vs. 42.86% (p < 0.001) and 41.94% vs. 0% (p < 0.001)]. CS correlated with high aldosterone at diagnosis (p < 0.001) and low postoperative aldosterone levels at 1 month (p = 0.019). Postoperative biochemical hypoaldosteronism was more frequent in patients with CS >50% (70% vs. 16.67%, p = 0.014). In multivariable analysis, a CS >50% was associated with complete biochemical cure (OR 125, 95%CI 11.904-5,000; p = 0.001) and hypertension remission (OR 12.19, 95%CI 2.074-250; p = 0.023).

CONCLUSION

A CS >50% was an independent predictor of complete clinical and biochemical cure. Moreover, it can predict unilateral PA and postoperative biochemical hypoaldosteronism. Our findings underscore the usefulness of CS for clinical decision-making.

Intraindividual variability of serum aldosterone and its implication for primary aldosteronism screening

CONTEXT

Primary aldosteronism (PA) screening relies on an elevated aldosterone to renin ratio with a minimum aldosterone level, which varies from 10 to 15 ng/dL (277 to 415.5 pmol/L) using immunoassay.

AIM

To evaluate intraindividual coefficient of variation (CV) of aldosterone and aldosterone to direct renin concentration ratio (A/DRC) and its impact on PA screening.

METHODS

A total of 671 aldosterone and DRC measurements were performed by the same chemiluminescence assays in a large cohort of 216 patients with confirmed PA and at least two screenings.

RESULTS

The median intraindividual CV of aldosterone and A/DRC was 26.8% and 26.7%. Almost 40% of the patients had at least one aldosterone level <15 ng/dL, 19.9% had at least two aldosterone levels <15 ng/dL and 16.2% had mean aldosterone levels <15 ng/dL. A lower cut-off of 10 ng/dL was associated with false negative rates for PA screening of 14.3% for a single aldosterone measurement, 4.6% for two aldosterone measurements and only 2.3% for mean aldosterone levels. Considering the minimum aldosterone, true positive rate of aldosterone thresholds was 85.7% for 10 ng/dL and 61.6% for 15 ng/dL. An A/DRC >2 ng/dL/µIU/mL had a true positive rate for PA diagnosis of 94.4% and 98.4% when based on one or two assessments, respectively. CV of aldosterone and A/DRC were not affected by sex, use of interfering anti-hypertensive medications, PA lateralization, hypokalemia, age and number of hormone measurements.

CONCLUSION

Aldosterone concentrations had a high CV in PA patients, which results in an elevated rate of false negative test in a single screening for PA. Therefore, PA screening should be based in at least two screenings with concomitant aldosterone and renin measurements.

Phosphodiesterase 2A and 3B variants are associated with primary aldosteronism

Familial primary aldosteronism (PA) is rare and mostly diagnosed in early-onset hypertension (HT). However, 'sporadic' bilateral adrenal hyperplasia (BAH) is the most frequent cause of PA and remains without genetic etiology in most cases. Our aim was to investigate new genetic defects associated with BAH and PA. We performed whole-exome sequencing (paired blood and adrenal tissue) in six patients with PA caused by BAH that underwent unilateral adrenalectomy. Additionally, we conducted functional studies in adrenal hyperplastic tissue and transfected cells to confirm the pathogenicity of the identified genetic variants. Rare germline variants in phosphodiesterase 2A (PDE2A) and 3B (PDE3B) genes were identified in three patients. The PDE2A heterozygous variant (p.Ile629Val) was identified in a patient with BAH and early-onset HT at 13 years of age. Two PDE3B heterozygous variants (p.Arg217Gln and p.Gly392Val) were identified in patients with BAH and HT diagnosed at 18 and 33 years of age, respectively. A strong PDE2A staining was found in all cases of BAH in zona glomerulosa and/or micronodules (that were also positive for CYP11B2). PKA activity in frozen tissue was significantly higher in BAH from patients harboring PDE2A and PDE3B variants. PDE2A and PDE3B variants significantly reduced protein expression in mutant transfected cells compared to WT. Interestingly, PDE2A and PDE3B variants increased SGK1 and SCNN1G/ENaCg at mRNA or protein levels. In conclusion, PDE2A and PDE3B variants were associated with PA caused by BAH. These novel genetic findings expand the spectrum of genetic etiologies of PA.

SUN-195 Bilateral Aldosterone-Producing Adenomas: A New Subtype of Bilateral Primary Aldosteronism?

Background: Primary aldosteronism (PA) is the most common cause of endocrine hypertension (HT). PA subtypes include aldosterone-producing adenomas (APA) and bilateral adrenal hyperplasia. To date, few PA patients with bilateral adenomas have been reported, but only one case was well characterized by anatomopathological analysis and clinical outcome after adrenal sparing surgery (1).

Clinical case: A 53-year-old woman was referred to investigate resistant HT and hypokalemia. (3.0 mEq/L). PA screening revealed aldosterone (A) of 37.9 ng/dL, renin (R) < 1.6 (4.4-46.1 mUI/L), A/R ratio of 24.8. Confirmatory testing confirmed PA diagnosis: seated saline infusion test (A= 83.3 ng/dL) and intravenous furosemide test (R= 3.1 mUI/L; positive test <13 mUI/L). Hypercortisolism investigation revealed a non-suppressible cortisol after an overnight 1 mg low-dose dexamethasone suppression [cortisol (C)= 2.9 μg/dL and dexamethasone= 701 (˃130 ng/dL)], and normal urinary free cortisol, midnight salivary cortisol, plasma DHEAS and ACTH levels. Computed tomography demonstrated bilateral adrenal nodules without adrenal thickening: 3.5 cm right nodule (pre-contrast density of 7UH density; absolute wash-out of 71%) and 2.5 cm left nodule (pre-contrast density of 8UH density; absolute wash-out of 78%). Sequential adrenal venous (AV) sampling (AVS) under continuous cosyntropin infusion showed a lateralization index of 3.4 (bilateral disease <4). Then, the patient underwent right adrenalectomy and left nodulectomy. In the postoperative period, she presented normalization of K⁺ levels and complete HT remission. She remained under hydrocortisone replacement for 2 months. After 2 months, biochemical evaluation revealed normal basal cortisol levels (13.3 µg/dL) and biochemical cure of PA (A= 3.1 ng/dL and R= 15.3 mUI/L). Currently, she doesn’t have symptoms of adrenal insufficiency after discontinuation of hydrocortisone. Anatomopathological analysis showed bilateral adenomas (Weiss score of 0) in both sides without adjacent hyperplasia. CYP11B2 immunohistochemistry displayed a strong staining in 50% of cells in the right adenoma and in 30% of cells in the left adenoma. Few aldosterone-producing cell clusters (APCC) were identified in the right zona glomerulosa, which is a frequent finding in normal adrenals.

Conclusion: We herein described a very rare case of PA caused by bilateral-producing adenomas, confirmed by AVS and CYP11B2 staining after adrenal sparing surgery.

KCNJ5 Somatic Mutation Is a Predictor of Hypertension Remission After Adrenalectomy for Unilateral Primary Aldosteronism

CONTEXT

Primary aldosteronism (PA) is the most common cause of endocrine hypertension (HT). HT remission (defined as blood pressure <140/90 mm Hg without antihypertensive drugs) has been reported in approximately 50% of patients with unilateral PA after adrenalectomy. HT duration and severity are predictors of blood pressure response, but the prognostic role of somatic KCNJ5 mutations is unclear.

OBJECTIVE

To determine clinical and molecular features associated with HT remission after adrenalectomy in patients with unilateral PA.

METHODS

We retrospectively evaluated 100 patients with PA (60 women; median age at diagnosis 48 years with a median follow-up of 26 months). Anatomopathological analysis revealed 90 aldosterone-producing adenomas, 1 carcinoma, and 9 unilateral adrenal hyperplasias. All patients had biochemical cure after unilateral adrenalectomy. KCNJ5 gene was sequenced in 76 cases.

RESULTS

KCNJ5 mutations were identified in 33 of 76 (43.4%) tumors: p.Gly151Arg (n = 17), p.Leu168Arg (n = 15), and p.Glu145Gln (n = 1). HT remission was reported in 37 of 100 (37%) patients. Among patients with HT remission, 73% were women (P = 0.04), 48.6% used more than three antihypertensive medications (P = 0.0001), and 64.9% had HT duration <10 years (P = 0.0015) compared with those without HT remission. Somatic KCNJ5 mutations were associated with female sex (P = 0.004), larger nodules (P = 0.001), and HT remission (P = 0.0001). In multivariate analysis, only a somatic KCNJ5 mutation was an independent predictor of HT remission after adrenalectomy (P = 0.004).

CONCLUSION

The presence of a KCNJ5 somatic mutation is an independent predictor of HT remission after unilateral adrenalectomy in patients with unilateral PA.

In vivo response to growth hormone-releasing peptide-6 in adrenocorticotropin-dependent Cushing's syndrome by lung carcinoid tumor is associated with growth hormone secretagogue receptor type 1a mRNA expression

GH secretagogues (GHS) have been used for the differential diagnosis of ACTH-dependent Cushing's syndrome (CS) since 1997 due to their ability to increase ACTH and cortisol levels in Cushing's disease. The aim of this study was to correlate ACTH response to GH-releasing peptide-6 (GHRP-6) in vivo with GH secretagogue receptor type 1a (GHSR-1a) mRNA expression in a patient with lung carcinoid tumor. The patient was a 26-yr-old male with diagnosis of ACTH-dependent CS. He presented negative responses to human CRH and desmopressin tests; yet, a significant increase in ACTH after the GHRP-6 test was observed. Sellar magnetic resonance imaging (MRI) showed slight posterior hypointensity, but bilateral petrosal sinus sampling did not show central gradient. Computed tomography (CT) and MRI of thorax/abdomen/cervical were negative and 111In-pentetreotide scintigraphy depicted abnormal uptake on the right lung. The patient was submitted to right thoracotomy for exeresis of lung nodule and hilar lymph node which were characterized as atypical lung carcinoid tumor and he presented clinical and laboratorial remission after surgery. GHSR-1a mRNA expression was studied with real-time quantitative PCR and tumor data were compared with fragments of normal lung and pituitary. There was a higher GHSR-1a expression in the lung carcinoid tumor as compared with normal tissues. The ACTH response to GHRP-6 in a patient with ectopic ACTH production by a lung carcinoid tumor was associated with GHSR-1a expression in the tumor tissue, suggesting an association between GHSR-1a mRNA overexpression and the in vivo response to GHS.

Effect of coronary angioplasty on electrocardiographic changes in patients with unstable angina secondary to left anterior descending coronary artery disease

The effect of semiemergent percutaneous transluminal coronary angioplasty on clinical and electrocardiographic (ECG) variables was assessed in 76 patients with unstable angina secondary to an isolated severe proximal left anterior descending coronary artery stenosis. All patients manifested symmetric T wave inversion in two or more anterior ECG leads. Wall motion abnormalities were present in 37 patients on ventriculography before dilation. Angioplasty was successful in 70 patients (92%), resulting in a reduction in luminal diameter stenosis from 91 +/- 8% to 21 +/- 6%, with no major acute procedure-related complications observed. The other six patients underwent semiurgent (less than 48 h) coronary artery bypass surgery and three patients experienced a myocardial infarction (before bypass surgery in two). Serial ECGs revealed complete resolution of ST-T wave changes in 51% of patients at 14 weeks and in 90% at 28 weeks. In contrast, prolongation of the corrected QT interval, which was present in 16 patients (8%), normalized within 48 h of successful angioplasty. Twelve of these 16 patients with a prolonged QT interval had nonocclusive thrombus formation and poor collateral circulation on angiography. Patients were followed up for 6 to 43 months (mean 23 +/- 10). Angiographic evidence of restenosis was present in 34% of patients, all of whom underwent a successful second or third procedure. One death occurred at 8 months after successful angioplasty. Wall motion abnormalities had completely resolved in 13 of 15 patients who underwent repeat ventriculography, at which time 10 had a normal ECG. This study demonstrates that ECG changes may persist for up to 7 months in patients who undergo successful angioplasty for severe left anterior descending coronary artery disease and unstable angina. Semiemergent angioplasty was associated with a high initial success rate and excellent long-term outcome.

Emergent coronary angioplasty in the treatment of acute ischemic mitral regurgitation: long-term results in five cases

Severe mitral regurgitation in the setting of an evolving myocardial infarction is associated with a high operative mortality rate. Five patients with acute severe mitral regurgitation secondary to ischemic posterior papillary muscle dysfunction underwent emergent percutaneous transluminal coronary angioplasty. Two patients were in cardiogenic shock and required intraaortic balloon counterpulsation. Angioplasty resulted in rapid improvement in hemodynamic variables, and all patients were discharged at a mean of 10 days after the procedure. Long-term follow-up study (mean 35 +/- 6 months) revealed normal mitral valve function angiographically and by Doppler echocardiography in four patients. Repeat angioplasty was required in one patient, and another underwent coronary artery bypass surgery without valve replacement for restenosis. One patient developed progressive mitral regurgitation and required elective mitral valve replacement 12 months after angioplasty. These preliminary findings suggest that emergent coronary angioplasty is a useful therapeutic intervention in the treatment of ischemic mitral regurgitation and is associated with a favorable long-term outcome.

Coronary air embolism during coronary angioplasty

A case is described in which the use of the Hartzler microcatheter during coronary angioplasty resulted in coronary air embolism. The recognition, prevention, and mechanism of this occurrence are discussed.

The usefulness of the lateral projection in the assessment of the right coronary artery during percutaneous transluminal coronary angioplasty

Optimum coronary angiographic definition of lesion morphology and side branch orientation is important during percutaneous transluminal coronary angioplasty (PTCA) to enhance the ease and safety of guidewire passage. This study was performed to compare the efficacy of the lateral (LAT) projection to conventional angiographic views for right coronary artery (RCA) evaluation pre- and post-PTCA. In 45 consecutive patients undergoing PTCA of 56 RCA lesions, the LAT was available to evaluate 40 lesions pre- and 44 lesions post-PTCA. Angiographic comparison of the LAT versus standard LAO, LAO cranial, and RAO views were performed by two experienced angiographers with consensus reading. The LAT was the best projection for assessing lesion morphology pre-PTCA in 19/40 (48%) and in 19/44 (43%) post-PTCA, while the LAT was significantly better (P less than or equal to 0.01) than standard views for assessing side branch orientation (48/56, 86%) and post-PTCA intimal disruption (18/33, 55%). In addition, LAT was the best view for assessing mid RCA lesions 13/21 (62%) pre-PTCA and 12/27 (44%) post-PTCA, while post-PTCA intimal disruption was best detected by LAT in 14/24 (58%). Lesions only recognized in the LAT view occurred in five instances, four involving right ventricular branch ostia and one involving the proximal posterior descending. Thus, the LAT projection appears helpful during PTCA to assess lesion morphology, eccentricity, side branch orientation, and intimal disruption pre- and post-PTCA as an adjunct to conventional views.

Pheochromocytoma presenting with Prinzmetal's angina

A patient with a pheochromocytoma presented with profound hypertension and the clinical syndrome of coronary artery spasm after the initiation of beta blockade therapy. It is postulated that intense unopposed alpha receptor stimulation can precipitate coronary artery spasm in susceptible persons with this tumor.

Tuberculous aortitis presenting with an aortoduodenal fistula: a case report

An elderly man with tuberculous aortitis presented with massive gastrointestinal bleeding resulting from an aortoduodenal fistula. Aortic resection was successful, and he has done well over a 12 year period. The organism was recovered from the aorta and also seen on section of the neighboring lymph nodes. Although tuberculous aortitis is rare, it should be considered in a patient with prior history of tuberculosis who has developed evidence of aortic disease, aneurysm, or massive gastrointestinal bleeding.

Pulmonary edema following conversion of tachyarrhythmia. A case following burst atrial pacing

Restoration of normal sinus rhythm is usually followed by improved hemodynamics. By contrast, pulmonary edema and cardiovascular collapse have been reported following successful electrical reversion of various tachyarrhythmias to normal sinus rhythm. The mechanism for this adverse reaction is not clear but has been thought to relate, at least in part, to electrical myocardial damage from the countershock. This report describes a patient in whom this complication occurred on two occasions, first following external countershock and subsequently following burst atrial pacing. Thus, conversion to sinus rhythm may be responsible for this phenomenon independent of the method of conversion.

Use of pulmonary artery pressure and pacing catheter during PTCA

A balloon-tipped pacing catheter capable of monitoring pulmonary artery pressure and providing standby right ventricular pacing was used in 20 percutaneous transluminal coronary angioplasties (PTCAs), without complication. The catheter was easily inserted in all cases (mean 85 sec) and achieved satisfactory pacing threshold in 17 patients (mean 7.5 ma). The design of this catheter theoretically reduces the risk of right ventricular perforation and tamponade, which may be increased during PTCA.

Cardiac tamponade following percutaneous transluminal coronary angioplasty: four case reports

Percutaneous transluminal coronary angioplasty (PTCA) has had complications related to dilating catheters and guide wires such as coronary artery dissection, spasm, rupture, and perforation. This report describes four patients who developed cardiac tamponade following PTCA, presumably from right ventricular (RV) perforation. All four received large doses of heparin during PTCA and three received antiplatelet therapy. In three cases, cardiac tamponade occurred several hours after PTCA. All patients did well following operative intervention and no patient required repair of a cardiac perforation. We postulate that impaired hemostasis in the presence of an otherwise inconsequential RV perforation causes tamponade. Three alternatives to provide standby pacing are proposed.