Cardiogenic shock from decompensated heart failure is associated with significant morbidity and mortality. Mechanical circulatory support (MCS) improves haemodynamics and reverses organ dysfunction in critically ill patients with cardiogenic shock. This paper summarises the main modalities of mechanical support and their physiological impact, practical considerations, advantages and disadvantages to facilitate a holistic approach in managing a potentially lethal pathology. To date, there remains a lack of large randomised controlled trials to support the use of any mechanical support strategy. Consequently, meta-analyses, registry data and expert consensus in the form of society guidelines are relied upon. Currently, randomised trials are in progress to assess the efficacy of a percutaneous assist device (Impella) and extracorporeal membrane oxygenation. Mechanical support options are centred around the use of counter pulsation and percutaneous assist devices and the use of an extracorporeal pump and are hence varied in means of application, degree of haemodynamic benefit and potential complications. Regardless of future innovations, a timely multidisciplinary approach that incorporates both patient and institutional considerations will always be crucial to a successful outcome.