POMC and primary aldosteronism: According to the literature and our experience using AVS in primary aldosteronism (PA) cases, the following factors might interfere with the assessment of lateralization in ACTH-independent CS: (1) a stress reaction involving increased cortisol release, (2) fluctuating levels of cortisol induced by ACTH secretion, and (3) different dilutional effects in the right and left adrenals due to the adrenal venous (AV) anatomy [11].