Purpose: This case report describes the occurrence of acute postoperative liver and renal failure after bicaval orthotopic heart transplantation (OHT) due to stenosis of the inferior vena cava (IVC)-right atrial (RA) anastomosis. We also discuss the role of measuring femoral venous pressure and transesophageal echocardiography (TEE) in establishing the diagnosis. Clinical features: A 42-yr-old female patient with idiopathic dilated cardiomyopathy underwent an OHT, using the bicaval anastomotic technique. During the first 12 hr postoperatively she developed unexplained kidney and liver failure. Her left and right ventricular functions were excellent and the right and left sided filling pressures were normal. The femoral pressure was elevated while the RA pressure was normal. An emergent TEE showed colour-flow and Doppler characteristics consistent with IVC-RA anastomotic stenosis. Emergent surgical re-exploration was undertaken; a hemostatic suture was found at the RA cannulation site that had caused the constriction of the IVC-RA anastomosis. Conclusions: Acute liver and renal failure after OHT can have multiple causes including ischemia due to a low flow state. This case demonstrates the importance of doing a detailed intraoperative TEE after OHT, and the importance of repeating the intraoperative examination after any hemostatic sutures are placed. Femoral venous pressure monitoring can be a useful diagnostic tool in detecting IVC-RA stenosis.