Handheld vital microscopes allow for direct observation of the sublingual microcirculatory perfusion during cardiac surgery. Through the use of handheld vital microscopes, it has been shown that cardiac surgery with cardiopulmonary bypass is associated with reduced and heterogenous microcirculatory perfusion. Microcirculatory impairment can result in inadequate tissue perfusion, leading to perioperative complications and poor outcome. Because microcirculatory impairment can occur despite stable or improved global hemodynamics, there is a yet unmet need for specific monitoring of the microcirculation. Technological advancements may facilitate point-of-care monitoring of microcirculatory perfusion using automated real-time analysis of microcirculatory measurements. Thus, microcirculatory monitoring may create new opportunities for specific microcirculatory treatment as part of hemodynamic management. The implementation of microcirculatory variables into personalized treatment concepts has the potential to improve hemodynamic management during cardiac surgery and thereby improve patient outcomes. Therefore, specific treatment strategies need to be developed to prevent or treat alterations of the microcirculatory perfusion. In the future, the use of handheld vital microscopes for microcirculatory monitoring may help to improve hemodynamic management and outcomes for patients undergoing cardiac surgical procedures.