Patients with heart failure require special considerations in the perioperative setting given the challenges caused by heart failure pathophysiology. This pathophysiology is complex and involves several mechanisms that contribute to both disease progression and the clinical syndrome, including cardiac remodeling, neurohormonal activation, and resultant hemodynamic derangements. Anesthetic management of these patients requires diligence at all stages of care. Preoperative assessment includes risk stratification, management of comorbid conditions, and heart failure medication management. Anesthetic agents have differing effects on hemodynamics and selection of these agents must be aimed at preventing hemodynamic collapse in patients with heart failure. In addition, the increased risk of intraoperative complications among these patients often necessitates means of invasive hemodynamic monitoring and use of vasopressor or inotropic support. Finally, the postoperative care of heart failure patients requires attention to the volume status of these patients, as well as considerations for pain management and modulation of the surgical stress response. In this review article, we aim to review how the pathophysiologic mechanisms and changes that occur with heart failure impact anesthetic management and patient-centered perioperative care.