An 80-year-old man with chronic bronchitis and hypertension was admitted with rectal cancer and cholecystolithiasis. Under general and epidural anesthesia, laparoscopic cholecysytectomy was performed with slightly elevated EtCO2. He underwent head-down tilt for laparoscopic rectectal amputation. Twenty five minutes after positioning, he developed ventricular tachycardia and died. Autopsy showed acute myocardial infarction super-imposed on the scar of lateral wall from old infarction. The laparoscopic operating techniques have become popular, but we do not know the safety limits of the pneumoperitoneal pressure and the angle of head-down tilt position. In our case, the cardiac event occurred 25 minutes after head-down tilt, and the head-down tilt position when combined with pneumoperitoneum may have a fatal influence on high-risk cardiac patients.