Intra-aortic balloon pump support in patients undergoing durable left ventricular assist device implantation: contemporary evidence and practical considerations

The role of intra-aortic balloon pump (IABP) use in optimizing patients for durable left ventricular assist device (LVAD) implantation is being reevaluated in the era of modern centrifugal, magnetically levitated pumps. A comprehensive PubMed literature review was conducted including studies published from the 1980s through 2025, corresponding to the era in which IABP therapy became established as standard of care. Emerging data suggest that IABP may provide meaningful physiologic unloading, improve right-sided pressures, and enhance end-organ perfusion in select LVAD candidates. Axillary-access IABP has further expanded its utility by enabling early ambulation and prolonged support consistent with contemporary enhanced recovery principles. Comparative analyses indicate that while complications such as limb ischemia and bleeding remain relevant, preoperative IABP does not appear to worsen postoperative outcomes and may offer hemodynamic advantages without increasing short-term mortality. Nevertheless, evidence remains heterogeneous, and direct comparisons with percutaneous ventricular assist devices and extracorporeal membrane oxygenation (ECMO) are limited. This review synthesizes current data regarding IABP physiology, access strategy, patient selection, perioperative outcomes, and areas of ongoing uncertainty in relation to LVAD implantation. Improved mechanistic understanding and prospective standardized investigations will be essential to define the appropriate role of IABP within modern LVAD optimization pathways.