In the presence of cirrhosis, aortic valve replacement has a significant risk for mortality because of bleeding from coagulopathy, renal failure, and infection. This report outlines a case and management analysis of aortic valve replacement (AVR), and orthotopic liver transplantation (OLT). Case presentation. A 40-year-old man with cirrhosis secondary to hepatitis B was evaluated for liver transplantation. He had history of hepatic encephalopathy, spontaneous bacterial peritonitis with Child C, score 11 and Meld 26. Echocardiography showed severe aortic regurgitation (AR) with enlarged LV. Pulmonary function was reported mild to moderate restrictive pattern. Due to severe AR our cardiologist recommended to do AVR prior to transplantation. He underwent metallic AVR and within 4 months he received orthotopic liver transplantation. He tolerated both operations. On 2 years follow up he has normal liver, heart, and lung function. Surgical procedures involving the heart and the liver are rare and have been confined to either combined heart transplantation and OLT or coronary artery bypass graft surgery and OLT. AVR and pulmonic valve vegetectomy for bacterial endocarditis after OLT have also been reported. There is only one case in English literature underwent combine AVR and liver transplantation with 2 other cases were reported OLT before AVR. The management of this patient, who had cardiac and hepatic disease, demonstrates the problems associated with this disease combination and poses serious questions regarding the prioritization of surgical and anesthetic management. There are some issues about which operation should be done first. Also the aetiology of AVR and the type of prosthetic valve should be considered. As described in this case report, prioritizing AVR as the first procedure was successful in this particular patient. However, each patient must be evaluated individually by considering known or estimated risk factors.