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Background  Lipomatous hypertrophy of the atrial septum (LHAS) is an anomaly of the heart. It is characterized by an infiltration of adipocytes into myocytes of the interatrial septum, sparing the fossa ovalis, which gives a characteristic hourglass-shaped image. Due to the progress in imaging techniques, it can be recognized more frequently, but it is still often misdiagnosed.    Case presentation  We present a case of 65-year-old woman with an incidentally discovered lipomatous hypertrophy of the atrial septum during cardiac surgery, which has caused the technical problems for surgeons with bicaval cannulation and visualization of the operated structures of the heart. Due to the unclear shadow in the lung parenchyma, the patient had preoperative computed tomography (CT) done, but the study report focused only on the lung description, neglecting visible changes in the structure of the heart. Based on the standardly performed intra-operative transesophageal echocardiography (TEE), as well as by analyzing the chest X-ray and CT scans, the diagnosis of LHAS was made. It allowed the surgeon to leave the mass intact, thus not increasing the risk of the baseline surgery.    Conclusions  LHAS is a rare but increasingly recognized anomaly of the heart. Contemporary diagnostic methods allow to diagnose and make the right therapeutic decisions. The utility of TEE and analysis of X-ray images, in this case, allowed the surgeon to recognize LHAS, and because of its histologically benign nature and asymptomatic course, to leave this change intact. Surgical treatment should be limited only to cases of patients with life-threatening cardiovascular complications.

Lipomatous hypertrophy of the atrial septum – a benign heart anomaly causing unexpected surgical problems: a case report