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Detection of microbial nucleic acid was performed by real-time PCR, using in-house assays for adenovirus,6 human parvovirus B197 and enterovirus,8 while commercial assays were used for Epstein-Barr virus (artus EBV, Qiagen, Hilden, Germany), human herpesvirus 6 (Light Mix, TIB Molbiol, Berlin, Germany) and cytomegalovirus (Cobas Amplicor CMV monitor test, Roche, Branchburg, New Jersey, USA).Endomyocardial specimens obtained for light microscopy were fixed with formalin, embedded in paraffin, sliced into 5 μm sections, and stained with H&E as well as haematoxylin phloxine saffron and Congo stains for light microscopic examination.We used Siemens 1.5 T scanners for MRI (Siemens Avanto and Siemens Sonata; Siemens Medical Systems, Erlangen, Germany).

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial.See: cardiomyopathy is characterised by left ventricular dilation and dysfunction in the absence of coronary disease, valvular disease or hypertension.1 Approximately 20% of admittances for decompensated heart failure are due to dilated cardiomyopathy,2 which probably represents the end-stage phenotype of almost any kind of global insult to the myocardium.Accordingly, the list of potential causes of dilated cardiomyopathy is long.1 The diagnostic work-up is usually limited to physical examination, blood tests, echocardiography and coronary angiography.2 More often than not, these tests fail to reveal the aetiology of the disease, and the patients are diagnosed with ‘idiopathic’ dilated cardiomyopathy.3 They then receive generic treatment for heart failure, leaving the question of causality unanswered and the potential for tailored treatment unmet in a disease with high mortality and morbidity.3 4Outcome in dilated cardiomyopathy depends on aetiology.3 Dilated cardiomyopathy caused by systemic inflammatory disease requires specific treatment, and some causes of dilated cardiomyopathy predispose to malignant arrhythmia, strengthening the indication for cardioverter-defibrillator (ICD) implantation.The value of employing each of these modalities in patients with initially unexplained dilated cardiomyopathy, and in particular the value of a comprehensive, multimodality work-up, has not been systematically investigated.We aimed to evaluate the diagnostic yield and therapeutic consequences of a multimodality diagnostic investigation, beyond physical examination, echocardiography, coronary angiography and blood tests, in a contemporary cohort of patients with ‘idiopathic’ dilated cardiomyopathy.

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We assumed that a thorough diagnostic evaluation would yield an aetiological diagnosis in a substantial number of patients, with considerable impact on therapeutic and follow-up strategies.

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