Catastrophic multisystem arterial thromboembolism masked by acute ST-elevation myocardial infarction and cardiogenic shock in a rheumatic mitral stenosis patient: A case report

Abstract Background Severe rheumatic mitral stenosis with atrial fibrillation creates a highly thrombogenic left atrial substrate, particularly when anticoagulation is inadequate. Coronary embolism may present as ST-elevation myocardial infarction and can mask simultaneous systemic arterial embolisation. Case summary A 60-year-old woman with severe rheumatic mitral stenosis, marked left atrial enlargement, atrial fibrillation, and irregular anticoagulation presented with ST-elevation myocardial infarction complicated by cardiogenic shock. Coronary angiography revealed thrombotic occlusion of multiple distal coronary branches without significant underlying atherosclerosis, consistent with coronary thromboembolism. Manual aspiration thrombectomy restored TIMI grade 3 flow. Despite partial haemodynamic stabilisation, the patient developed persistent vasopressor dependence, anuria, severe metabolic acidosis, and progressive bilateral lower-limb ischaemia. Computed tomography angiography subsequently demonstrated multisystem arterial thromboembolism involving the superior mesenteric artery, abdominal aorta, bilateral iliac arteries, splenic artery, and bilateral renal arteries. The patient died from refractory multiorgan failure. Discussion This case illustrates that, in advanced rheumatic mitral stenosis and atrial fibrillation with inadequate anticoagulation, STEMI may be only one manifestation of a systemic embolic storm. Distal multivessel coronary occlusions without atherosclerosis, persistent metabolic deterioration after coronary reperfusion, and limb or visceral ischaemia should prompt early systemic vascular evaluation when clinically feasible.