We report the successful management of intra-operative pulmonary hypertension in a patient with mitral valve insufficiency and portal hypertension. A 48-year-old male with portal hypertension presented for a portosystemic shunt. Previously undiagnosed mitral valve insufficiency and pulmonary hypertension complicated his anaesthetic management. His intra-operative course was marked by systolic hypotension, pulmonary hypertension and a reduction in cardiac output. The use of nitric oxide in this patient reduced right ventricular afterload, increased cardiac output, without exacerbating pre-existing systolic hypotension.