Abstract Body: Introduction
Primary aldosteronism (PA) is a common cause of resistant hypertension. The standard of care for bilateral hyperaldosteronism is medical management, while surgery is often preferred for unilateral cases.


Case Presentation:
We report the case of a 53-year-old female with an 18-year history of hypertension. She presented with uncontrolled blood pressure despite adherence to seven antihypertensive medications.
Blood tests, including creatinine, urea, and electrolytes, were within normal limits, as was the renal ultrasound. Serum aldosterone was 136.3 pg/mL, and plasma renin activity was 0.23 ng/mL/hr, with a ratio of 593. Her antihypertensive medications were changed to hydralazine, moxonidine, and verapamil.
A Seated Saline Suppression Test performed a month later, with 2 liters of saline infused over 4 hours, showed that serum aldosterone levels failed to suppress, confirming the diagnosis of PA.
Three-Phase adrenal CT revealed a well-defined adenoma in the left adrenal gland measuring 4.5 x 3.4 cm, and a small adenoma in the right adrenal gland measuring 1.2 x 1 cm. Adrenal Vein Sampling indicated excess aldosterone secretion from both adrenal glands, confirming bilaterality.Therefore, high-dose spironolactone was added to her antihypertensive regimen; however, her BP remained elevated after 2 months of therapy.
The option of surgically removing the adrenal gland with the larger adenoma in hopes of reducing the total burden of aldosterone was discussed with the patient as the only remaining option of improving her BP control. The patient agreed and a laparoscopic left adrenalectomy was performed. Histopathological examination ruled out malignancy.
Immediate preoperative BP was 151/90 mmHg. The surgery was uneventful. All antihypertensive medications were withheld postoperatively. On the third postoperative day her BP was consistently below 130 mmHg systolic and below 85 mmHg diastolic. Her BP remained well controlled with gradual resumption of bisoprolol 5 mg/day and spironolactone 50 mg/day

Conclusion
Despite the bilaterality of primary aldosteronism in this case, the patient's hypertension did not respond to medical treatment, necessitating surgical intervention. The unilateral adrenalectomy of the larger adenoma proved sufficient to significantly improve her persistently elevated blood pressure. This case underscores the potential efficacy of targeted surgical treatment in managing resistant hypertension associated with bilateral adrenal disease.