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A reappraisal of the physiological premises of intra-aortic counterpulsation may underpin the rationale to maintain IABP as a valuable therapeutic option for patients with acute decompensated heart failure and tissue hypoperfusion. Several pathophysiological features differ between myocardial infarction- and acute decompensated heart failure\u2013related hypoperfusion, encompassing cardiogenic shock severity, filling status, systemic vascular resistances rise, and adaptation to chronic (if preexisting) left ventricular dysfunction. IABP combines a more substantial effect on left ventricular afterload with a modest increase in cardiac output and would therefore be most suitable in clinical scenarios characterized by a disproportionate increase in afterload without profound hemodynamic compromise. The acute decompensated heart failure syndrome is characterized by exquisite afterload-sensitivity of cardiac output and may be an ideal setting for counterpulsation. Several hemodynamic variables have been shown to predict response to IABP within this scenario, potentially guiding appropriate patient selection. Finally, acute decompensated heart failure with hypoperfusion may frequently represent an end stage in the heart failure history: IABP may provide sufficient hemodynamic support and prompt end-organ function recovery in view of more definitive heart replacement therapies while preserving ambulation when used with a transaxillary approach.<\/jats:p>","DOI":"10.1161\/circheartfailure.121.008527","type":"journal-article","created":{"date-parts":[[2021,10,28]],"date-time":"2021-10-28T09:00:15Z","timestamp":1635411615000},"update-policy":"https:\/\/doi.org\/10.1161\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":71,"title":["Intra-Aortic Balloon Pumping in Acute Decompensated Heart Failure With Hypoperfusion: From Pathophysiology to Clinical Practice"],"prefix":"10.1161","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5986-049X","authenticated-orcid":true,"given":"Luca","family":"Baldetti","sequence":"first","affiliation":[{"name":"IRCCS San Raffaele Scientific Institute, Milan, Italy (L.B., M.G., V.P., F.C., S.S., A.M.C.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Matteo","family":"Pagnesi","sequence":"additional","affiliation":[{"name":"Department of Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Italy (M.P., M.M.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9709-6082","authenticated-orcid":true,"given":"Mario","family":"Gramegna","sequence":"additional","affiliation":[{"name":"IRCCS San Raffaele Scientific Institute, Milan, Italy (L.B., M.G., V.P., F.C., S.S., A.M.C.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3131-0565","authenticated-orcid":true,"given":"Alessandro","family":"Belletti","sequence":"additional","affiliation":[{"name":"Cardiac Intensive Care Unit, Department of Anesthesia and Intensive Care (A. 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