Objective: Our objective was to analyze the potential advantage of combining an intraaortic balloon pump with a transthoracic Hemopump device (Medtronic, Inc., Minneapolis, Minn.) (Nimbus Medical, Inc., Rancho Cordova, Calif.). Methods: Twelve sheep underwent implantation of a transthoracic Hemopump device and an intraaortic balloon pump. In the first series (n = 6), we analyzed the influence of the counterpulsation on the performance of the Hemopump device. In the second group (n = 6), hemodynamic changes, myocardial wall thickening, organ perfusion, and myocardial perfusion (determined with colored microspheres) were analyzed under the following conditions: (1) control situation, (2) during application of coronary stenosis, (3) during support with the Hemopump device, and (4) during support with the Hemopump device combined with intraaortic balloon pump support. Results: In the first series, we found that addition of counterpulsation reduced output with the Hemopump device by 11.1% +/- 6%. In the second series, it was shown that coronary stenosis significantly reduced contractility (rate of pressure change and wall thickening) but did not cause hemodynamic collapse. Myocardial blood Bow was significantly reduced in the poststenotic subendocardial regions (mean subendocardial blood flow dropped from 78 +/- 33 to 24 +/- 17 ml/min/100 gm; p = 0.0486). Support with the Hemopump device alone improved the ratio of subendocardial to subepicardial blood flow, but endocardial underperfusion remained (analysis of variance, p < 0.001). The Hemopump device with an intraaortic balloon pump completely restored perfusion in poststenotic regions. Peripheral organ perfusion did not change during ischemia or mechanical support. Conclusions: The association of balloon counterpulsation with the Hemopump device reduces the Hemopump output by 11% and increases myocardial blood flow to ischemic regions. Perfusion to peripheral organs remains unaltered. The transthoracic Hemopump device combined with an intraaortic balloon pump is an ideal support system for the ischemic, failing heart.