Right ventricular (RV) failure remains a major problem in cardiac surgery, particularly in the setting of heart transplantation and following institution of left ventricular support. Experimental studies have shown that RV function is derived from 2 sources: the free wall of the RV and the interventricular septum. Management of RV failure involves not only decreasing RV afterload, but also optimizing both contributions to RV function, which is best achieved by optimizing developed systemic pressure. Techniques for managing the pulmonary circulation and strategies for optimizing RV function in various clinical settings are presented.