WITH advances in surgical and anaesthetic techniques, patients who are previously deemed unsuitable are now presenting themselves for orthoptic liver transplantation (OLT). Age is no longer a strict exclusion; older patients (above 70 years) do just as well as the young (below 70). However, age-related illness take on greater significance. Patients with chronic liver failure can present with hypoxemia. This may be due to ascites, pleural effusion, ventilation-perfusion imbalances, or pulmonary hypertension. Hepatic pulmonary syndrome (HPS) is a triad of liver dysfunction, intrapulmonary vasodilation, and hypoxemia (PaO2 ,70 mm Hg on room air). Orthodeoxia (decrease in PaO2 .3 mm Hg on standing from supine) is also present. Hypoxemia due to HPS can be treated by OLT and is not a contraindication to surgery. Liver transplantation is associated with intense cardiovascular changes. Preoperative cardiovascular assessment can be difficult because these patients may not be ambulatory. This could include stress ECG, echocardiography, angiography, or MUGA scans. Patients with significant cardiovascular history were more prone to perioperative complications like arrhythmias, hypotension, myocardial infarct, and pulmonary edema. However, long-term survival after transplant was not affected. Pulmonary hypertension is often associated with the development of portal hypertension. Mild and moderate pulmonary hypertension (mean , 35 mm Hg) are not contraindications to surgery. Patients with increased pulmonary resistance and mean pulmonary artery pressures . 25 mm Hg did not have worse outcome after OLT.