The following are key points to remember from a state-of-the-art paper on novel devices for acute cardiorenal syndrome (CRS):

1. Recent insights into the pathophysiology of acute CRS in acute decompensated heart failure (ADHF) have indicated that not every rise in creatinine is associated with adverse outcomes.
2. Detection of persistent volume overload and diuretic resistance associated with creatinine rise may identify patients with true acute CRS.
3. On the basis of evolving understanding of acute CRS, evaluation of acute CRS should therefore include:
   • Careful assessment of clinical status to identify the presence of residual or persistent volume overload; and
   • Appropriate evaluation of renal tubular function to determine adequacy of the diuretic effect in terms of diuresis and/or natriuresis (or conversely the presence of diuretic resistance [DR] when such responses are inadequate).
4. More in-depth phenotyping is needed to identify pathologic processes in renal arterial perfusion, venous outflow, and microcirculatory-interstitial-lymphatic axis alterations that can contribute to acute CRS. Phenotyping patients at the bedside, assessing a combination of creatinine changes, DR, and volume overload can lead to actionable consequences.
5. Recently, various novel device-based interventions designed to target different pathophysiologic components of acute CRS are in early feasibility and proof-of-concept studies. These devices can target venous, arterial, and interstitial/lymphatic axis alterations.
6. Device-based interventions that act upon central venous pressure either restrict venous return via the vena cava (preCARDIA [Abiomed] and Doraya [Revamp Medical]) or work by increasing splanchnic compliance and hereby shifting blood from the stressed blood volume to the unstressed blood volume pool (e.g., splanchnic ablation for volume management). Alternatively, local reduction in renal venous pressure by the Doraya and Nephronyx may attain a similar goal by lowering renal pressure, allowing an enhanced diuretic response.
7. The WhiteSwell catheter reduces hydrostatic pressures at the outlet of the thoracic duct across the bifurcation of the jugular and innominate veins, enhancing lymphatic return and ultimately leading to enhanced interstitial decongestion.
8. The AquaPASS system (Aqua-Aerobic Systems) consists of a skin-contacting suit raising skin temperature and stimulating eccrine glands to produce odorless sweat, which is immediately vaporized through regional airflow. Increasing sweat reduces interstitial volume. The Reprieve system (Reprieve Cardiovascular) monitors urine output and uses a protocol-driven optimization of diuretic dose to attain adequate urine output.
9. All devices mentioned in this review have been tested only in small studies; pivotal studies further establishing their safety and efficacy are pending. As a result, none of the devices is currently ready for prime time.
10. Ongoing trials are necessary to determine the overall risk-benefit rate of these devices. However, appropriate trial endpoints that reflect improvement in cardiorenal trajectories remain elusive and highly controversial.

Clinical Topics: Heart Failure and Cardiomyopathies, Prevention, Acute Heart Failure, Chronic Heart Failure

Keywords: Acute Heart Failure, Cardiology Interventions, Cardio-Renal Syndrome, Diuretics, Secondary Prevention

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