Mechanical circulatory support devices (MCSDs) have revolutionized the management of advanced heart failure and critical cardiopulmonary conditions. These devices, categorized into temporary and long-term systems, provide crucial circulatory and respiratory support in patients with cardiogenic shock, refractory heart failure, and/or acute respiratory distress syndrome or act as a bridge to recovery or transplant. Temporary devices such as intra-aortic balloon pumps, percutaneous heart pumps, percutaneous ventricular assist devices (VADs), and dual-lumen cannulas are essential for acute hemodynamic stabilization. Long-term devices, including VADs and total artificial hearts (TAHs), offer durable solutions and may be used as a destination therapy or a bridge to heart transplant. Extracorporeal membrane oxygenation, also referred to as extracorporeal life support, provides cardiopulmonary support for patients with severe respiratory failure with or without cardiac failure. Despite their transformative role, MCSDs are associated with significant risks, including mechanical and medical complications. Imaging modalities such as echocardiography and CT are integral to optimal management of MCSDs and aid in device placement, functionality assessment, and early identification of complications, ensuring patient safety and improved outcomes. Recent advancements in device technology, including third-generation continuous-flow VADs and TAH systems, have led to improved survival and reduced complication rates. However, recent recalls and regulatory updates underscore the need for ongoing vigilance in device selection, implantation, and monitoring. The authors highlight the types of and indications for using MCSDs, their normal imaging appearances, and findings associated with common complications. The latest updates in MCSD technology are discussed, and the pivotal role of imaging in optimizing the management of patients with MCSDs is emphasized.