Case presentation: We are presenting the case of a 63-year-old female patient, in whom the etiology of heart failure raised diagnostic challenges. The patient had history of hypertension, ischemic stroke 10 years ago, and has been admitted in our clinic 3 years ago for NYHA class IV heart failure phenomena (dyspnea at rest and bilateral hydrothorax). The electrocardiogram showed sinus rhythm and complete LBBB. Transtho-racic echocardiography revealed the presence of a di-lated LV, severe mitral regurgitation, segmental kinetic abnormalities and severely reduced LVEF. The diagnosis of ischemic dilated cardiomyopathy was formula-ted, the phenomena of heart failure were compensated during hospitalization and the patient was recommen-ded to perform coronary angiography after discharge. The angiographic investigation was performed in a private center and revealed permeable epicardial coronary arteries, therefore the patient being discharged with the diagnosis of hypertrophic cardiomyopathy in the dilated stage. She returned to the outpatient clinic 1 year ago, accusing phenomena of left-sided heart failure and hyper-tension at home. The patient was readmitted to the clinic, transthoracic echocardiographic examination was performed, with the evaluation of ventricular asynchrony parameters, raising the suspicion of non-compaction dilated cardiomyopathy. Fabry and Pompe diseases were excluded by performing enzymatic tests. MGS type genetic analysis was also performed. Treatment was optimized and cardiac MRI was recom-mended before for resynchronization therapy. Cardiac MRI showed a typical appearance of ischemic dilated cardiomyopathy, with subepicardial and transmural fibrosis in the LAD corresponding territories, 20% apical aneurysm, hypertrabeculation of the apex and apical ½ of the lateral wall and moderate mitral regurgitation (anterior mitral valve prolapse and annular dilatation). The appearance of noncompaction has probably been due to severe LV dilation and severe wall motion abnormalities in this territory. The patient was schedu-led for CRT-D implantation. The peculiarity of the case is represented by the evolution towards heart failure in a patient with a previous myocardial infarction, with history without suggestive clinical ischemic episode, with angiographically pe-meable coronary arteries, and transthoracic echocardi-ography that raised the suspicion of LV non-compa-tion dilated cardiomyopathy, the final diagnosis being established by cardiac MRI.