Congestive hepatopathy in the setting of chronic heart failure is predominantly cholestatic. Severe hepatocellular injury can be seen in cardiogenic shock, usually in an acute setting with severe reduction in ejection fraction and with significant hypotension. Hepatic ischemia with preserved ejection fraction in the setting of atrial fibrillation has not been widely recognized, although mild elevations of liver enzymes have been seen in such patients in the chronic state. We present a patient with preserved ejection fraction, rapid atrial fibrillation with hypotension who had ischemic hepatitis, with aspartate aminotransferase and alanine aminotransferase over one thousand.