Device therapies in cardiorenal syndrome: an expert review.

Jeroen Dauw, Guillaume Baudry, Marta Cobo Marcos, Mateusz Guzik, Juan Carlos Lopez, Biykem Bozkurt, Gracjan Iwanek, Masatake Kobayashi, Òscar Miró, Peder Langeland Myhre, Alberto Palazzuoli, Jeffrey M Testani, Marco Metra, Piotr Ponikowski, Wilfried Mullens, Jan Biegus

Journal: ESC heart failure 2026;13(4):

PMID: 42611536

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Abstract

Managing cardiorenal syndrome in acute decompensated heart failure remains a major challenge in contemporary cardiology. While pharmacological decongestion with diuretics is the cornerstone of therapy and is effective in most patients, worsening renal function and diuretic resistance continue to pose challenges in selected cases. Device-based therapies are increasingly explored to target key pathophysiological mechanisms underlying cardiorenal dysfunction. This expert review builds on a conceptual framework for device-based therapies. Rather than cataloguing individual technologies, we apply a functional framework that classifies devices according to their primary mode of action: reduction of venous or lymphatic congestion ('pullers'), augmentation of arterial perfusion ('pushers'), and direct removal of sodium and/or fluid ('removers'). For each category, we integrate pathophysiological rationale with available clinical evidence, highlighting the predominance of early-phase physiological evidence and the need for randomized studies demonstrating benefit beyond optimized contemporary medical care.

Address: Cardiovascular Center Aalst, AZORG Hospital, Moorselbaan 164, Aalst 9300, Belgium.; INSERM, Centre Investigations Cliniques 1433, Inserm 1116 and INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN Network, Université de Lorraine, CHRU de Nancy, Nancy, France.; REICATRA, Recherche et Enseignement en IC Avancée, Transplantation, Assistance, Vandœuvre-lès-Nancy, France.; Cardiology Department, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain.; Centro de Investigación Biomédica en Red (CIBER Cardiovascular), Madrid, Spain.; Department of Cardiology, Clinical Department of Intensive Cardiac Care, Faculty of Medicine, Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland.; Cardiology Section, Winters Center for Heart Failure, Baylor College of Medicine, Houston, TX, USA.; Department of Cardiology, Tokyo Medical University, Tokyo, Japan.; Emergency Department, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain.; Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway.; Department of Cardiology, Akershus University Hospital, Lørenskog, Norway.; Institute of Clinical Medicine, University of Oslo, Oslo, Norway.; Cardiovascular Diseases Unit, Cardio Thoracic and Vascular Department, S. Maria Alle Scotte Hospital, University of Siena, Siena, Italy.; Section of Cardiovascular Medicine, Yale University, New Haven, CT, USA.; Department of Cardiology, Vita-Salute San Raffaele University, IRCCS San Raffaele Hospital, Milan, Italy.; Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium.; Biomedical Research Institute, Faculty of Medicine and Life Sciences, LCRC, UHasselt, Diepenbeek, Belgium.

DOI: 10.1093/eschf/xvag195

MeSH Terms: Cardio-Renal Syndrome, Humans, Heart Failure