Acute decompensated heart failure and fluid overload are the most common causes of hospitalization in heart failure patients and they often contribute to disease progression. Initial treatment encompasses intravenous diuretics, although there might be a percentage of patients refractory to this pharmacologic approach. New technologies have been developed to perform extracorporeal ultrafiltration in fluid-overloaded patients. Newer simplified devices permit ultrafiltration to be performed with peripheral venous access and low blood flows, making ultrafiltration feasible at most hospitals and acute care settings. Extracorporeal ultrafiltration then is prescribed and conducted by specialized teams and fluid removal is planned to restore a status of hydration close to normal. Recent clinical trials, and European and North American practice guidelines, suggest that ultrafiltration is reasonable for patients with refractory congestion not responding to medical therapy and assigned to this recommendation a class IIa, level of evidence B. It seems that a close collaboration between nephrologists and cardiologists may be the key for a collaborative therapeutic effort in heart failure patients. Further studies suggest that wearable technologies might become available soon to treat patients in ambulatory and de-hospitalized settings. These new technologies may help to cope with the increasing demand for care of chronic heart failure patients.