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Tricuspid regurgitation (TR) is a common valvular lesion which may affect morbidity and mortality. It can be related to an intrinsic abnormality of the tricuspid valve leaflets (organic) or secondary to annular dilatation (functional). Often organic and functional TR coexist in the same patient. A long-standing TR is associated with ascites, congestive hepatopathy, peripheral edema, renal failure, and abdominal fullness which significantly affect the outcome. In particular, the perioperative course may be complicated due to both the presence of comorbidities and the development of a severe postoperative right ventricle (RV) dysfunction. In fact, the TR may conceal a preoperative RV dysfunction due to a backflow in in the right atrium, which becomes overt only after the tricuspid valve (TV) repair/replacement (afterload mismatch). In light of this, an appropriate medical treatment before surgery may improve the performance of the RV, maximizing the result of the elective surgical therapy. The perioperative optimization should reduce the right atrial and ventricle overload, decrease the pulmonary vascular resistances, improve RV contractility and treat aggressively the arrhythmias. In doing so, the following rules should be considered: careful fluid administration, β1-agonists favored over α-agonists to treat hemodynamic instability, and maintenance of a normal-to-elevated heart rate. Since the TV repair/replacement needs mechanical ventilation in both open and percutaneous surgery, a careful volume and pharmacological management should be adopted to counteract the detrimental effect of the mechanical ventilation on the top of an already dysfunctional RV. In fact, in the context of RV failure the cardiac output is strictly dependent on the preload and the increase of the intrathoracic pressure, reducing the venous return, may lead to acute heart failure. The intraoperative administration of volume and vasoactive drugs, titrated on the basis of the transesophageal echocardiography, permit to support the RV intraoperatively. Paracorporeal mechanical hemodynamic support should be always available as "bail out" in the event of intractable RV failure. In conclusion the patients undergoing TV surgery are complex and only a detailed anesthesiologic and surgical workup may decrease the perioperative mortality and morbidity.