Tissue perfusion is the ultimate goal of a functional cardio-circulatory system and its integrity should remain the essential endeavor of all caregivers in charge of hemodynamically compromised patients. The postoperative cardiac patients are not the exception. Optimization of tissue perfusion after cardiac surgery is multifactorial and should be based upon invasive and non-invasive markers. Physiological elements to be considered and supported with medical therapy include: pre and afterload, cardiac contractility, heart rate and rhythm (determining cardiac output), analysis of systemic and pulmonary vascular resistances, evaluation of the systolic but also the diastolic function, and optimization of oxygen content, transport, extraction and consumption. All of the latter are to be managed taking into account elements related to microcirculation, cardiopulmonary and interventricular interactions and the neuro-humoral mechanisms triggered by the shock status. This conference will review decision-making processes, and therapeutic strategies related to general management principles, drugs (inotropic, lusitropic, vasodilator and vasoconstrictor medications), ventilation, and salvage therapies, amongst others.