A 59-year-old woman was admitted with atypical chest pain. Surface electrocardiography showed sinus rhythm with tall R wave in lead V1, northwest axis, clockwise rotation and suspicious left anterior fascicular block (figure 1). Echocardiography revealed a heterogeneous mass in the interventricular septum with protrusion into the right ventricular (RV) cavity and normal left and RV wall thickness. MRI suggested the diagnosis of lipoma involving the septum (figure 2). Close follow-up was decided as treatment strategy.

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Figure 1

Surface ECG of the patient.

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Figure 2

Axial T1 weighted magnetic resonance image suggesting the presence of benign lipoma (arrow) in the interventricular septum that has the same signal intensity as fat tissue.

Tall R wave in V1 may be present in different cardiac abnormalities such as posterior myocardial infarction, RV hypertrophy, hypertrophic cardiomyopathy, left septal fascicular block, Duchenne muscular dystrophy and Wolff-Parkinson-White patterns.1 This case suggests that cardiac tumours also should be kept in mind in the differential diagnosis of R in V1.