A 57-year-old 132-kg female (BMI 48.6) with end-stage cardiac failure is presented. Because of a progressive cardiomyopathy, the patient required a heart transplant. However, before receiving the transplant, major weight loss was deemed to be mandatory. Supervised dieting had manifestly failed, and thus a highly effective weight-reducing operation, biliopancreatic diversion, was performed. This resulted in a weight loss of 50.4 kg in 9 months. She then underwent successful cardiac transplantation, and progressed well for several months. She then developed severe psychiatric depression, withheld her medications and developed a lethal acute rejection phenomenon.