Background <p>CXCR4 PET/CT imaging has emerged as a tool for diagnosis and subtyping of primary aldosteronism (PA). But its prognostic value for postoperative blood pressure recovery has not been fully discussed.</p> Results <p>The lesional SUVmax to the contralateral adrenal tissue SUVmean ratio (LCR) was identified as an independent predictor of clinical success at both the 3-month and 6-month assessments. The AUC for LCR was 0.894 at the 3-month and 0.832 at the 6-month. Patients were divided into high and low LCR groups according to the optimal cut-off of 3.240. The high LCR group exhibited elevated CXCR4 and CYP11B2 expression, higher PAC level, a greater probability of achieving complete clinical success compared to the low LCR group. Moreover, LCR was correlated with lateralization index and contralateral suppression index.</p> Conclusions <p>LCR is a reliable independent predictor of postoperative blood pressure recovery in PA. Patients with LCR over 3.240 may benefit more from adrenalectomy. We recommend increased utilization of CXCR4 PET/CT for patients with PA.</p> Registration <p>ChiCTR2200062844. Registered 20 August 2022.</p>