A patient with alcohol induced end-stage liver disease developed cardiac arrest immediately after reperfusion during orthotopic liver transplantation. In our case, advanced age of the patient, alcohol-related severe liver disease with high ASA score, and myocardial dysfunction, combined with acute metabolic and hemodynamic changes throughout the surgery may have contributed to the development of postreperfusion syndrome resulting in cardiac arrest. Our patient required a total of 5 mg epinephrine, 200 mg lidocaine, 100 mEq NaHCO3, and 40 mEq calcium gluconate together with direct cardiac compressions and ventilation enriched 100% oxygen to regain sinusoidal rhythm. In conclusion, during severe postreperfusion syndrome, the collaboration between the surgical and anesthesia teams is crucial to overcome cardiac arrest. In an open abdomen, direct cardiac compressions through the transdiaphragmatic pericardial window instead of chest compressions were important to restore effective circulation during advanced life support.