Heart failure (HF), with or without ischaemic heart disease, remains the leading causes of death worldwide. 1 This can be attributed at least in part to the inability of the heart to regenerate damaged tissue. 2 As a result, the lost myocardium is replaced with fibrosis, initiating a series of subsequent events that lead to adverse ventricular remodelling and organ failure. 3 Cardiac stromal cells (CSC) are a heterogeneous population of non-cardiomyocyte CD45-, CD34-, CD31-and CD105+ cells including fibroblasts, resident in the heart

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Aims Understanding the aetiology of heart failure is crucial for treatment. Gadolinium cardiac magnetic resonance (CMR) is a powerful technique to distinguish dilated cardiomyopathy (DCM) from left ventricular (LV) dysfunction related to coronary artery disease (CAD). Methods and results Clinical case: a 61 years old Caucasian woman with a history of hypertension and dyslipidaemia presented to the emergency department of our hospital with pulmonary oedema and hypertensive crisis, requiring non-invasive ventilatory support. She complained about shortness of breath and exertional angina for almost one year. On admission, the echocardiography showed severe LV systolic dysfunction and severe functional mitral regurgitation (FMR). Troponin levels were slightly increased, and NT-proBNP was 2809 pg/ml. Once obtained clinical stability, anti-remodelling cardiac therapy was introduced and up titrated. Due to the history of angina and the new-onset severe LV systolic dysfunction, coronary angiography was performed, showing critical stenosis of the left main (LM) and of the proximal tract of the left anterior descending artery (LAD). In deciding the best treatment pathway for the patient evaluate myocardial viability and characterize myocardial tissue was of paramount importance. Subsequently, a CMR confirmed severe LV systolic dysfunction and severe functional mitral regurgitation but demonstrated myocardial viability, with no late gadolinium enhancement. Therefore the patient underwent surgical myocardial revascularization with triple coronary artery bypass grafts (left internal mammary artery-LAD, saphenous vein graft-obtuse marginal artery, saphenous vein graft-diagonal branch of LAD) and mitral valve repair (annuloplasty). The patient underwent a period of cardiac rehabilitation asymptomatic and in good clinical status. Three months later, echocardiography demonstrated an initial recovery of LV systolic dysfunction with signs of reverse cardiac remodelling and a good result of mitral valve repair. The patient is now on optimal medical therapy, free of symptoms and in good clinical and functional condition. Conclusions Cardiovascular magnetic resonance (CMR) is an excellent diagnostic tool in heart failure. This clinical case can be formative, confirming once again the importance of an accurate and complete diagnostic workup and a subsequent therapy of aetiology in heart failure.