Efficacy of Tolvaptan on Fluid Management After Cardiovascular Surgery Using Cardiopulmonary Bypass

Efficacy of tolvaptan in postoperative volume therapy for acute Stanford type A aortic dissection

BACKGROUND

Despite the increasing application of tolvaptan in cardiac surgery, there is no information on the use of tolvaptan in Stanford patients with type A aortic dissection. This study aimed to evaluate the postoperative clinical effects of tolvaptan in patients with type A aortic dissection  after tafter surgery.

METHODS

A retrospective analysis was performed on 45 patients treated for type A aortic dissection in our hospital from 2018 to 2020. These included 21 patients who were treated with tolvaptan (Group T) and 24 patients who received traditional diuretics (Group L). The hospital's electronic health records were used to obtain perioperative data.

RESULTS

Group T did not differ significantly from Group L in terms of the duration of mechanical ventilation, postoperative blood required, length of catecholamine use, or the amount of intravenous diuretic drugs administered (all P > 0.05). The development of postoperative atrial fibrillation was significantly less in the tolvaptan group (P = 0.023). The urine volumes and change in body weight loss were slightly higher in group T than in group L but the differences were non-significant (P > 0.05). Serum potassium, creatinine, and urea nitrogen levels did not differ between the groups in the week after surgery, At the same time, sodium was significantly higher in the Group T group on day 7 after transfer from the ICU (P = 0.001). In Group L, sodium levels were also elevated by day 7 (P = 0.001). On days 3 and 7, serum creatinine and urea nitrogen levels increased in both groups (both P < 0.05).

CONCLUSIONS

Both tolvaptan and traditional diuretics were found to be effective and safe for patients with acute Stanford type A aortic dissection. Moreover, tolvaptan may be associated with reducing the incidence of postoperative atrial fibrillation.

Peak Lag Between Plasma Vasopressin and Urine Aquaporin-2 Following Cardiac Surgery

Tolvaptan, a vasopressin type-2 receptor antagonist, is utilized to ameliorate fluid retention following cardiac surgery. However, the optimal timing of tolvaptan administration considering novel biomarkers remains unknown. We prospectively included patients who underwent cardiac surgery between 2016 and 2020. We measured perioperative trends of free water reabsorption mediators including plasma arginine vasopressin and urine aquaporin-2. A total of 20 patients (68 [60, 75] years old, 18 men) were included. Urine volume decreased gradually after the initial 3 hours following cardiac surgery. The plasma arginine vasopressin level increased significantly with a peak at postoperative 6 hours, whereas the urine aquaporin-2 level increased later with a delayed peak at postoperative 12 hours. As a result, urine aquaporin-2 relative to the plasma arginine vasopressin level, which represents the activity of the collecting ducts and indicates predicted responses to tolvaptan, was a minimum at postoperative 6 hours. Tolvaptan administration immediately after cardiac surgery might not be recommended given the transient refractoriness to tolvaptan probably due to the stunning of kidney collecting ducts.

Efficacy of tolvaptan for fluid management after cardiovascular surgery: A systematic review and meta-analysis of randomized control trials

The purpose of this study was to systematically search the literature and analyze evidence from randomized controlled trials (RCTs) comparing tolvaptan with conventional diuretics for postoperative fluid management in cardiac surgery patients. An electronic search of PubMed, Scopus, BioMed Central, CENTRAL (Cochrane Central Register of Controlled Trials) and Google scholar databases was carried out up to 1st December 2019. Four RCTs were included. Tolvaptan was co-administered with conventional diuretics in all the studies. The mean postoperative urine output was significantly greater in patients receiving tolvaptan as compared to controls (MD=0.39; 95% CI: 0.17 to 0.61; P=0.006, I²=48%). Body weight of patients on tolvaptan returned to pre-operative levels significantly earlier (MD=-1.57; 95% CI: -2.48 to -0.66; P=0.007, I²=50%). There was statistical significant difference in the highest postoperative serum sodium levels (MD=2.34; 95% CI: -1.65 to 3.03; p<0.00001, I²=0%), lowest serum sodium levels (MD=2.05; 95% CI: 1.41 to 2.68; p<0.00001, I²=0%) and mean serum sodium levels (MD=1.69; 95% CI: 0.98 to 2.40; p<0.00001, I²=0%) between the tolvaptan and control groups. Lowest serum potassium was significantly higher with tolvaptan as compared to the control group (MD=0.10; 95% CI: 0.01 to 0.18; P=0.03, I²=19%). There was no significant difference in the length of ICU stay or incidence of arrhythmias between the two groups. The quality of the included studies was not high. Within the limitations of our study, our results indicate that co-administration of tolvaptan with low dose of conventional diuretics significantly increases urine output while maintaining electrolyte balance in postoperative cardiac surgery patients. Faster return of body weight to pre-operative levels is evident with tolvaptan. Further high-quality RCTs are required to confirm this evidence.

The Role of Tolvaptan Administration After Cardiac Surgery: A Meta-Analysis

OBJECTIVE

To evaluate the efficacy and safety of tolvaptan in fluid management after cardiac surgery compared with conventional diuretic treatment.

DESIGN

Systematic review of the literature with meta-analyses.

SETTING

The Medline, Scopus, Cochrane Central Register of Controlled Trials, Clinicaltrials.gov, and Google Scholar databases were searched from inception to July 30, 2018.

PARTICIPANTS

The study comprised 759 patients undergoing cardiac surgery.

INTERVENTIONS

Tolvaptan administration (n = 397) or standard diuretic therapy (n = 398).

MEASUREMENTS AND MAIN RESULTS

Ten studies were included in the present meta-analysis. Tolvaptan administration was associated with a significantly faster return to preoperative body weight (mean difference [MD)] -1.48 d, 95% confidence interval [CI] -1.92 to 1.03), shorter duration of hospital stay (MD -2.58 d, 95% CI -5.09 to -0.07), lower incidence of acute kidney injury (odds ratio 0.34, 95% CI 0.16-0.69), and greater urine output (MD 0.47 L/d, 95% CI 0.25-0.69) and sodium levels (MD 2.85 mEq/L, 95% CI 1.90-3.80). No significant differences were present regarding duration of intensive care unit stay (MD -0.09 d, 95% CI -0.33 to 0.15), arrhythmia incidence (odds ratio 0.58, 95% CI 0.33-1.02), and serum creatinine values (MD -0.08 mg/dL, 95% CI -0.20 to 0.04).

CONCLUSIONS

The outcomes of the present meta-analysis suggest the promising role of tolvaptan administration in the management of fluid retention in patients after cardiac surgery. Future large-scale clinical trials should be conducted to fully elucidate its efficacy and to assess the optimal treatment protocol to be applied in the clinical setting.

Safety and Effectiveness of Tolvaptan Administration after Total Arch Replacement

BACKGROUND

Postoperative fluid overload in cardiovascular surgery is associated with increased mortality and morbidity. Recently, tolvaptan (TLV), a selective vasopressin V2 antagonist, has been used for perioperative fluid management. This study aimed to validate the safety and effectiveness of TLV administration after total arch replacement (TAR) using selective cerebral perfusion.

METHODS

From August 2016 to December 2016, 11 patients who had undergone TAR for thoracic aortic aneurysm were included in this study. In addition to the conventional diuretics furosemide (20 mg) and spironolactone (25 mg), TLV (7.5 mg) was administered orally.

RESULTS

TLV increased urine output 1-3 days after administration. Body weight was gradually and steadily reduced until discharge. Neither renal nor liver dysfunction was recognized during the TLV administration.

CONCLUSION

The concomitant use of TLV and conventional diuretics is safe and effective for fluid management after TAR using cardiopulmonary bypass, selective cerebral perfusion, and hypothermic circulatory arrest.