Current and advanced therapeutic strategies for volume expansion management in heart failure

INTRODUCTION: Congestion and/or volume expansion is primary driver of adverse outcomes in patients with heart failure. Despite the widespread use of loop diuretics as first-line therapy, diuretic resistance frequently limits effective decongestion. Consequently, alternative pharmacological and device-based strategies have emerged to address persistent or refractory congestion. AREAS COVERED: This review summarizes current evidence on conventional and advanced decongestive approaches in heart failure. We discuss optimization of loop diuretics and sequential nephron blockade, as well as adjunctive strategies such as saline supplementation. In addition, the review addresses the use of extracorporeal and mechanical decongestive strategies in selected patients, some of which are already incorporated into clinical practice, while others remain under development: peripheral ultrafiltration, peritoneal dialysis for chronic refractory heart failure, lower-limb compression therapy, and emerging technologies such as the Reprieve system designed for targeted fluid removal. The literature was identified through a structured search of PubMed/MEDLINE, prioritizing randomized trials, meta-analyses, and high-quality observational studies. EXPERT OPINION: While loop diuretics remain the cornerstone of decongestion, a more individualized and pathophysiology-driven approach is warranted. Advanced strategies may offer benefit in selected patients, but robust comparative trials are needed to define optimal timing, patient selection, and integration into routine heart failure care.