Mechanical circulatory support (MCS) is frequently used in patients with cardiogenic shock to restore adequate organ perfusion, improve hemodynamic, reduce catecholamine-related adverse events, and prevent development of organ failure. Intra-aortic balloon pump (IABP) is usually the first line device used among currently available MCS systems, it is easily inserted at bedside, and associated with low complications rate. Despite its widespread use, a recent small, randomized study suggested that early implantation of IABP does not improve short-term outcomes in patients with Society of Cardiovascular Angiography Class B to D heart-failure related cardiogenic shock. In this article, we discuss possible limitations of recent studies on IABP, as well as updated evidence on effects on outcome and optimal patient selection for IABP support in patients with heart-failure related cardiogenic shock.