Introduction: Dilated cardiomyopathy (DCM) in-volves the presence of an enlarged left ventricle/heart chambers with subsequent systolic dysfunction in the absence of coronary artery/valvular heart disease or hypertension. Cardiac multimodality imaging is being increasingly used for identifying the aetiology, while a selected number of patients undergo cardiac resyn-chronization therapy (CRT). Establishing the aetiology in DCM, sometimes, could be an issue.

Methods: We present you a case of an idiopathic DCM male patient who received CRT after remaining symp-tomatic despite adequate medical therapy.

Results: A 40-year old male patient presented with aggravating dyspnoea and frequent palpitations for the previous 6 months. He was diagnosed with a left bundle branch block 4 years prior to current admissi-on and with a myocardial infarction 3 months earlier, when transthoracic echocardiography revealed a left ventricular ejection fraction (LVEF) of 20% and an end-diastolic left ventricular diameter of 70 mm. The aetiology of DCM was considered to be ischemic at that time. Coronary arteries catheterization revealed normal coronary arteries. Cardiac magnetic resonance (CMR) raised the suspicion of cardiac sarcoidosis, the second possible cause of the DCM. However, the latter was infirmed when the patient was implanted with a CRT-D. Evolution was favourable, the patient being a super-responder with a 20% increase in LVEF 3 weeks post-implant.

Conclusions: CMR is used for its tissue characterizati-on abilities, namely in identifying fibrosis’ presence and pattern. However, these patterns are interchangeable and there is a lack of consensus in diagnostic criteria. As such, interpretations should be considered as highly suggestive and not clear diagnostic and be judged in the clinical context. Treating DCM is a challenge and multimodality imaging, in the absence of a holistic approach may rather become a foe instead of a friend.