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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 (\u2018pullers\u2019), augmentation of arterial perfusion (\u2018pushers\u2019), and direct removal of sodium and\/or fluid (\u2018removers\u2019). 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.<\/jats:p>","DOI":"10.1093\/eschf\/xvag195","type":"journal-article","created":{"date-parts":[[2026,8,15]],"date-time":"2026-08-15T12:48:50Z","timestamp":1786798130000},"source":"Crossref","is-referenced-by-count":0,"title":["Device therapies in cardiorenal syndrome: an expert review"],"prefix":"10.1093","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-4605-3450","authenticated-orcid":false,"given":"Jeroen","family":"Dauw","sequence":"first","affiliation":[{"name":"Cardiovascular Center Aalst, AZORG Hospital , Moorselbaan 164, Aalst 9300 ,","place":["Belgium"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9200-2729","authenticated-orcid":false,"given":"Guillaume","family":"Baudry","sequence":"additional","affiliation":[{"name":"INSERM, Centre Investigations Cliniques 1433, Inserm 1116 and INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN Network, Universit\u00e9 de Lorraine, CHRU de Nancy , Nancy ,","place":["France"]},{"name":"REICATRA, Recherche et Enseignement en IC Avanc\u00e9e, Transplantation, Assistance , Vand\u0153uvre-l\u00e8s-Nancy ,","place":["France"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marta","family":"Cobo Marcos","sequence":"additional","affiliation":[{"name":"Cardiology Department, Hospital Universitario Puerta de Hierro-Majadahonda , Madrid ,","place":["Spain"]},{"name":"Centro de Investigaci\u00f3n Biom\u00e9dica en Red (CIBER Cardiovascular) , Madrid ,","place":["Spain"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9711-6568","authenticated-orcid":false,"given":"Mateusz","family":"Guzik","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Clinical Department of Intensive Cardiac Care, Faculty of Medicine, Institute of Heart Diseases, Wroclaw Medical University , Wroclaw ,","place":["Poland"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Juan Carlos","family":"Lopez","sequence":"additional","affiliation":[{"name":"Cardiology Department, Hospital Universitario Puerta de Hierro-Majadahonda , Madrid ,","place":["Spain"]},{"name":"Centro de Investigaci\u00f3n Biom\u00e9dica en Red (CIBER Cardiovascular) , Madrid ,","place":["Spain"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6362-0253","authenticated-orcid":false,"given":"Biykem","family":"Bozkurt","sequence":"additional","affiliation":[{"name":"Cardiology Section, Winters Center for Heart Failure, Baylor College of Medicine , Houston, TX ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8574-9963","authenticated-orcid":false,"given":"Gracjan","family":"Iwanek","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Clinical Department of Intensive Cardiac Care, Faculty of Medicine, Institute of Heart Diseases, Wroclaw Medical University , Wroclaw ,","place":["Poland"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Masatake","family":"Kobayashi","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Tokyo Medical University , Tokyo ,","place":["Japan"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7924-9751","authenticated-orcid":false,"given":"\u00d2scar","family":"Mir\u00f3","sequence":"additional","affiliation":[{"name":"Emergency Department, Hospital Clinic, IDIBAPS, University of Barcelona , Barcelona ,","place":["Spain"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Peder Langeland","family":"Myhre","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Oslo University Hospital Rikshospitalet , Oslo ,","place":["Norway"]},{"name":"Department of Cardiology, Akershus University Hospital , L\u00f8renskog ,","place":["Norway"]},{"name":"Institute of Clinical Medicine, University of Oslo , Oslo ,","place":["Norway"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6235-984X","authenticated-orcid":false,"given":"Alberto","family":"Palazzuoli","sequence":"additional","affiliation":[{"name":"Cardiovascular Diseases Unit, Cardio Thoracic and Vascular Department, S. Maria Alle Scotte Hospital, University of Siena , Siena ,","place":["Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jeffrey M","family":"Testani","sequence":"additional","affiliation":[{"name":"Section of Cardiovascular Medicine, Yale University , New Haven, CT ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marco","family":"Metra","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Vita-Salute San Raffaele University, IRCCS San Raffaele Hospital , Milan ,","place":["Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Piotr","family":"Ponikowski","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Clinical Department of Intensive Cardiac Care, Faculty of Medicine, Institute of Heart Diseases, Wroclaw Medical University , Wroclaw ,","place":["Poland"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9995-8590","authenticated-orcid":false,"given":"Wilfried","family":"Mullens","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Ziekenhuis Oost-Limburg , Genk ,","place":["Belgium"]},{"name":"Biomedical Research Institute, Faculty of Medicine and Life Sciences, LCRC, UHasselt , Diepenbeek ,","place":["Belgium"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9977-7722","authenticated-orcid":false,"given":"Jan","family":"Biegus","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Clinical Department of Intensive Cardiac Care, Faculty of Medicine, Institute of Heart Diseases, Wroclaw Medical University , Wroclaw ,","place":["Poland"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2026,8,18]]},"reference":[{"key":"2026081810485686500_xvag195-B1","doi-asserted-by":"publisher","first-page":"455","DOI":"10.1093\/eurheartj\/eht386","article-title":"Renal impairment, worsening renal function, and outcome in patients with heart failure: an updated meta-analysis","volume":"35","author":"Damman","year":"2014","journal-title":"Eur Heart J"},{"key":"2026081810485686500_xvag195-B2","doi-asserted-by":"publisher","first-page":"1304","DOI":"10.1016\/j.kint.2019.02.022","article-title":"Heart failure in chronic kidney disease: conclusions from a kidney disease: improving global outcomes (KDIGO) controversies conference","volume":"95","author":"House","year":"2019","journal-title":"Kidney Int"},{"key":"2026081810485686500_xvag195-B3","doi-asserted-by":"publisher","first-page":"2016","DOI":"10.1161\/CIRCULATIONAHA.117.030112","article-title":"Worsening renal function in patients with acute heart failure undergoing aggressive diuresis is not associated with tubular injury","volume":"137","author":"Ahmad","year":"2018","journal-title":"Circulation"},{"key":"2026081810485686500_xvag195-B4","doi-asserted-by":"publisher","first-page":"584","DOI":"10.1002\/ejhf.1697","article-title":"Evaluation of kidney function throughout the heart failure trajectory\u2014a position statement from the Heart Failure Association of the European Society of Cardiology","volume":"22","author":"Mullens","year":"2020","journal-title":"Eur J Heart Fail"},{"key":"2026081810485686500_xvag195-B5","doi-asserted-by":"publisher","first-page":"1505","DOI":"10.1002\/ejhf.1236","article-title":"Advanced heart failure: a position statement of the Heart Failure Association of the European Society of Cardiology","volume":"20","author":"Crespo-Leiro","year":"2018","journal-title":"Eur J Heart Fail"},{"key":"2026081810485686500_xvag195-B6","doi-asserted-by":"publisher","first-page":"881","DOI":"10.1016\/0002-9343(77)90541-1","article-title":"The role of renin and aldosterone in the salt retention of edema","volume":"63","author":"Chonko","year":"1977","journal-title":"Am J Med"},{"key":"2026081810485686500_xvag195-B7","doi-asserted-by":"publisher","first-page":"1602","DOI":"10.1161\/CIRCRESAHA.122.319989","article-title":"Cardiorenal syndrome: the role of neural connections between the heart and the kidneys","volume":"130","author":"Patel","year":"2022","journal-title":"Circ Res"},{"key":"2026081810485686500_xvag195-B8","doi-asserted-by":"publisher","first-page":"10","DOI":"10.2165\/00003495-199000394-00004","article-title":"Role of the kidney in congestive heart failure. 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