A 77-year-old hypertensive man (height, 179.2 cm; weight, 71.4 kg) was scheduled for elective extended right hepatectomy for cholangiocarcinoma. Although the patient was elderly, he could ski asymptomatically. The preoperative electrocardiogram was normal, and no further cardiovascular examinations were performed. Before anesthesia induction, a 3-lead electrocardiogram (ECG) showed rapid upsloping ST depression in lead II, but the patient did not complain of any ischemic symptoms. Following epidural catheter insertion at the level of Th8–Th9, general anesthesia was induced with propofol, rocuronium, fentanyl, and remifentanil and maintained with desflurane. After a smooth intubation, a right radial arterial catheter and a central venous catheter were placed. Vital signs before liver resection were stable, and fluid administration was restricted to maintain a low central venous pressure (CVP) to reduce blood loss during liver resection. After the start of liver resection, the mean arterial pressure (MAP) decreased to 50 mmHg, and ECG showed slow upsloping ST depression in lead II. The authors speculated that this hypotension occurred due to bleeding and compression of the inferior vena cava by the surgeon. Therefore, multiple doses of phenylephrine and a bolus of 5% albumin solution were administered. Despite these measures, hypotension with a MAP of 50–60 mmHg persisted for approximately 30 min. The management of hypotension became gradually difficult, and MAP decreased to a nadir of 36 mmHg. Subsequently, multiple doses of norepinephrine and epinephrine were administered, followed by continuous infusion. The patient did not respond to this, and ECG showed horizontal ST depression in lead II. Transesophageal echocardiography (TEE)—performed to diagnose the cause of refractory hypotension—revealed severe hypokinesis of the anteroseptal wall, a left ventricular ejection fraction (LVEF) of 20%, and severe mitral regurgitation (MR). We considered the diagnosis of CS owing to the occurrence of MI intraoperatively; the surgery had to be suspended in the middle of the parenchymal resection. An intra-aortic balloon pump (IABP) was placed following immediate abdominal closure, and the patient was transferred to a nearby hybrid operating room for coronary angiography (CAG). Blood sampling at this time revealed 273 ng/L of troponin-I and 10.1 g/dL of hemoglobin. CAG revealed severe stenosis of the left main coronary trunk (LMT). An intravascular ultrasound study (IVUS) revealed the presence of a stenotic lesion with ulceration in the mid-portion of the LMT. An emergent PCI was performed, and the final CAG showed optimal dilatation of the LMT stent. Myocardial wall motion and MR improved, and blood pressure stabilized, but oxygen saturation decreased to a nadir of 76% (FiO2 100%) due to pulmonary edema. Additionally, an elevated CVP of up to 20 mmHg caused severe bleeding in the resection plane of the liver. Therefore, femoro-femoral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was initiated to reduce organ congestion, and the patient was transferred to the intensive care unit. During VA-ECMO, unfractionated heparin was infused at 200–400 units/h to maintain an activated clotting time of 160–200 s. The patient was weaned off VA-ECMO after improvement of the pulmonary edema, 18 h later. Hepatectomy, which had been suspended, was successfully completed after 36 h with the support of IABP and infusions of norepinephrine (0.05 μg/kg/min), dobutamine (5 μg/kg/min), and landiolol (2 μg/kg/min). The patient bled continuously for 36 h (volume 6500 mL) till the reoperation, owing to the hemi-resected liver parenchyma and heparin administration for VA-ECMO. Twenty units of packed red blood cells, 38 units of frozen fresh plasma, and 60 units of platelet concentrates were transfused. After reoperation, the continuous bleeding improved. The IABP was removed on postoperative day (POD) 4 of the initial surgery, and the trachea was extubated on POD 7. Although the patient died due to sepsis during the course of treatment for postoperative liver failure on POD 90, he remained free from any other cardiovascular events during hospitalization.