RATIONALE: Cardiac surgery can cause arrhythmias and low cardiac output syndrome through various mechanisms, including cardiac manipulation, systemic inflammation, myocardial hypoxia, cardioplegic arrest, and ischemia resulting from coronary or graft occlusion. Symmetric peripheral gangrene is a rare but serious complication that can occur after cardiac surgery. Here, we present a case of symmetric peripheral gangrene shortly after cardiac surgery for mitral valve replacement. PATIENT CONCERNS: A 76-year-old male with rheumatic heart disease and severe mitral stenosis underwent mitral valve replacement. He experienced postoperative bleeding on the first day after the cardiac surgery. After experiencing ventricular fibrillation, cardiogenic shock, acute hepatic failure, and disseminated intravascular coagulation (DIC), he developed symmetrical peripheral gangrene on the fifth day after cardiac surgery. DIAGNOSES: The patient presented with postoperative bleeding, cardiogenic shock, and DIC complicated by symmetrical peripheral gangrene following cardiac surgery. INTERVENTIONS: During cardiosurgery intensive care unit admission, the patient received positive inotropic agents and vasopressors, blood transfusion, and antithrombotic treatment with low -molecular-weight heparin. Because of the severe general condition of the patient, amputation was not performed. OUTCOMES: The patient died on the 80th day after cardiac surgery because of multiorgan failure and DIC. LESSONS: Physicians should be vigilant for comorbid symmetrical peripheral gangrene in patients undergoing cardiac surgery who present with postoperative bleeding, cardiogenic shock, and DIC. Early recognition of acrocyanosis, prompt management of cardiogenic shock, correction of anemia, hemodynamic stabilization, and properly controlled use of anticoagulation may help prevent symmetrical peripheral gangrene.