Intra-aortic balloon counterpulsation is a product of an endeavor begun more than 3 decades ago. First the concept, then applications of inflating a nonthrombogenic balloon within the aorta during diastole were explored. The intra-aortic balloon is timed to inflate with aortic valve closure. Two options are available for deflation timing: (1) conventional timing, where deflation is estimated to be completed at some point during isovolumetric contraction, prior to ejection; and (2) R wave deflation, also known as real timing, where deflation is triggered by each QRS complex to occur during isovolumetric contraction or early systole. Although clinical implementation of both conventional and real timing was introduced in 1968, limited information about these methods of deflation is currently available. This article elucidates the differences between these models and suggests implications for clinical practice and further research.