Mechanical circulatory support (MCS) devices have revolutionized the management of patients with advanced heart failure and cardiogenic shock. Temporary and durable MCS modalities are now integral in the support of patients with advanced heart failure and cardiogenic shock in an effort to stabilize hemodynamics, supporting recovery, bridging to transplantation, or serving as destination therapy. With technological advancements—including miniaturized cannulas and improved pump designs—MCS devices are more versatile and easier to deploy on short notice but remain susceptible to complications, which negatively affect hemodynamics and patient outcomes. Accurate assessment of both native cardiac function pre-device deployment and device performance is critical throughout all phases to allow for optimal MCS therapy and improved patient outcomes. A skilled non-invasive advanced cardiac imaging team, therefore, is integral to the advanced heart failure and mechanical device team. This will include the cardiac non-invasive imaging laboratory and the cardiac radiology and anesthesia department members. Echocardiography, including transthoracic (TTE) and transesophageal echocardiography (TEE), plays a significant role in the success of the team. Echocardiography is easily accessible, is cost effective, has bedside availability, and has real-time evaluation capabilities in skilled hands. Imaging pre-, intra-, and post-device implantation are all equally important in device deployment and follow up. Echocardiography supports decisions on cannula placement, ventricular decompression, septal alignment, valvular function, and cannula patency. For intra-aortic balloon pumps (IABP), extracorporeal membrane oxygenation (ECMO), and ventricular assist devices (VAD), echocardiographic assessment ensures optimal device function and early recognition of complications, such as suction events, thrombus, or important aortic regurgitation. Multimodality imaging—including cardiac computerized tomography (cCT), cardiac nuclear scans, and cardiac magnetic resonance imaging (cMRI)—all complement echocardiography by providing anatomic detail, pump function, cardiac physiology and can evaluate structural–mechanical complications or infections. Imaging is also essential for optimizing LVAD speed and flow, monitoring native heart recovery, and determining long-term device performance. A careful, meticulous, systematically structured imaging approach facilitates precision in diagnosis, therapy adjustment, and complication management. This comprehensive review outlines the principles and applications of imaging across various MCS platforms, emphasizing the indispensable role of the imaging team and the vital role of echocardiography in improving outcomes and guiding therapy in this complex patient population.