Intra-aortic balloon pump (IABP) counterpulsation is the most widely used form of left ventricular mechanical support today, with more than 160,000 patients worldwide receiving this therapy annually. Currently, IABP support is indicated in patients with acute left ventricular systolic failure and cardiogenic shock whose management remains particularly complex and still today characterized by high mortality rates. While the available clinical practice guidelines support the indication to IABP placement in acute myocardial infarction (MI) with cardiogenic shock, recent clinical studies have questioned the benefits of IABP in these clinical settings. However, the rate of complications associated to IABP use is high and therefore the eventual IABP benefits must be weighed over the disadvantages. IABP still represents a very important mechanical support, however recent scientific evidences have challenged the value of its use, thus, it will be absolutely necessary to confirm these findings in a definitive RCT. This review will describe the role of IABP in the modern clinical practice.