[Non-pharmacological therapy of decompensated heart failure: the extracorporeal ultrafiltration]

High-dose diuretic therapy frequently leads to diuretic resistance in patients with decompensated heart failure, through several pathophysiological mechanisms. Ultrafiltration is a non-pharmacological technique that is effective in reducing fluid overload, and nowadays it can be performed out of the hemodialysis unit, because of the availability of simplified tools. The ultrafiltrate production is obtained by an extracorporeal circuit with a filter inside. The procedure requires a veno-venous access and hemodynamic stability is guaranteed by circulatory refilling at the pulmonary and systemic levels. Ultrafiltration in patients with severely decompensated heart failure can promptly reduce fluid overload, improve cardiac function, relieve symptoms, increase diuresis, restore normal plasma levels of sodium, and reduce neurohumoral activation. Several studies have demonstrated that beneficial effects of ultrafiltration are maintained also in the following period. Indeed, recently published randomized studies showed middle-term beneficial effects of ultrafiltration therapy, with a reduction of decompensated heart failure episodes and of hospitalizations due to heart failure.