Tolvaptan (TLV) is an oral selective vasopressin 2 receptor antagonist that acts on the distal nephrons, causing a loss of electrolyte-free water. To date, its early administration in very elderly patients after repeat hospitalizations for acute decompensated heart failure (ADHF) despite receiving optimal medical therapy has not been evaluated. Fifty-six ADHF patients who were >80 years old and had been repeatedly hospitalized were retrospectively enrolled in this study. Twenty-five patients (14 men; mean age 86.7 ± 5.3 years; control group) received standard therapy and 31 patients (15 men; mean age 85.5 ± 4.5 years; TLV group) received oral TLV within 24 h of admission. The rate of worsening renal function was significantly lower in the TLV group than in the control group (13 vs. 40%, P < 0.05). The duration of the return to body weight at a steady state was significantly shorter in the TLV group (5.3 ± 2.8 days) than in the control group (13.9 ± 9.2 days, P < 0.01). Consequently, the hospitalization period in the TLV group (13.5 ± 5.9 days) was significantly shorter than that in the control group (24.7 ± 12.3 days, P < 0.01). In conclusion, the early administration of TLV to very elderly patients who underwent repeat hospitalizations for ADHF resulted in immediate decongestion and thus reduced the hospitalization period with a lower incidence of worsening renal function.