Oriented to Thoracic Transplant Recipients -- November 1999


Laser Perforation of Heart Successful Treatment - Or Is It?


Transmyocardial Revascularization with a Carbon Dioxide Laser in Patients with End-Stage Coronary Artery Disease

O.H. Frazier, Robert J. March, Keith A. Horvath, for the Transmyocardial Carbon Dioxide Laser Revascularization Study Group

Background: The construction of subendocardial channels to perfuse ischemic areas of the myocardium has been investigated since the 1950s. We assessed the safety and efficacy of transmyocardial revascularization with a carbon dioxide laser in patients with refractory angina and left ventricular free-wall ischemia that was not amenable to direct coronary revascularization.

Methods. In a prospective, controlled, multicenter trial, we randomly assigned 91 patients to undergo transmyocardial revascularization and 101 patients to receive continued medical treatment. The severity of angina (according to the Canadian Cardiovascular Society [CCS] classification), quality of life, and cardiac perfusion (as assessed by thallium-201 scanning) were evaluated at base line and 3, 6, and 12 months after randomization.

Results. At 12 months, angina had improved by at least two CCS classes in 72 percent of the patients assigned to transmyocardial revascularization, as compared with 13 percent of the patients assigned to medical treatment who continued medical treatment (P<0.001).

Patients in the transmyocardial-revascularization group also had a significantly improved quality of life as compared with the medical-treatment group. Myocardial perfusion improved by 20 percent in the transmyocardial-revascularization group and worsened by 27 percent in the medical-treatment group (P=0.002).

In the first year of follow-up, 2 percent of patients assigned to undergo transmyocardial revascularization were hospitalized because of unstable angina, as compared with 69 percent of patients assigned to medical treatment (P<0.001). The perioperative mortality rate associated with transmyocardial revascularization was 3 percent. The rate of survival at 12 months was 85 percent in the transmyocardial-revascularization group and 79 percent in the medical-treatment group (P--0.50).

Conclusions. In patients with angina refractory to medical treatment and coronary artery disease that precluded coronary-artery bypass surgery or percutaneous transluminal coronary angioplasty, transmyocardial revascularization improved cardiac perfusion and clinical status over a 12-month period.

(N Engl J Med 1999;341:1021-8.)


Transmyocardial Laser Revascularization

(Success is only in the patient's imagination. The study is flawed so say these doctors. Ed.)

To perform transmyocardial laser revascularization, the surgeon exposes the beating heart through a lateral thoracotomy, places a laser (carbon dioxide or holmium) on the epicardial surface of the left ventricle, and applies sufficient energy to create small channels from the epicardial to the endocardial surfaces. During a typical procedure, 10 to 50 such channels are created. Initially, these small, laser-created transmyocardial channels were thought to improve the perfusion of ischemic myocardium by providing it with direct access to oxygen-rich left ventricular blood, but it was subsequently found that the channels quickly occlude after the procedure.

Nonetheless, initial observational studies of transmyocardial revascularization in patients with severe angina showed that the procedure improved symptoms.

In some studies, the relief of angina was sustained, whereas in others, it was relatively short-lived. The effect of transmyocardial revascularization on myocardial perfusion was also inconsistent, with improved perfusion in some studies and no change in others. In most studies, the procedure did not improve regional or global left ventricular function.

On the basis of these observational assessments, three multicenter, randomized, controlled trials -- one in the United Kingdom and two in the United States --have now compared transmyocardial revas-cularization with medical therapy in patients with severe angina for whom balloon angioplasty or bypass grafting was deemed unsuitable.

In all three trials, there was an improvement in the frequency and severity of angina after transmyocardial revascularization, although the extent of improvement varied: angina diminished by at least two Canadian Cardiovascular Society (ccs) classes in 34 percent of patients in the British study but in about 75 percent of patients in the U.S. studies.

Partly on the basis of the results of these and other studies, both the carbon dioxide laser and the holmium laser have recently been approved by the Food and Drug Administration for use in transmyocardial revascularization. In our opinion, however, these apparently impressive results must be viewed with caution, since angina is a subjective condition.

In the two US studies, reported in this issue of the Journal by Allen et al. and Frazier et al., angina was assessed on site by investigators who were presumably enthusiastic about transmyocardial revascularization.

In both studies, a blinded, independent assessment of angina was also performed, and the results were reported to be within one CCS class of the on-site results in 80 percent of patients. Unfortunately, neither report delineates how often the independent and on-site assessors agreed that angina had improved by two or more classes. Since the actual results of the independent assessment are not provided, one wonders whether it was as favorable as the on-site assessment.

The placebo effect of a thoracotomy should not be underestimated, particularly in patients for whom all therapeutic options have been exhausted and particularly when the procedure is combined with the use of a laser device. In all three trials, patients were eligible for enrollment only if they had severe, activity-limiting angina despite aggressive antianginal medical therapy and only if bypass grafting and percutaneous revascularization were considered impossible. Many such patients are eager to embrace any procedure that offers hope of improvement. For laypersons and physicians alike, the word "laser" is synonymous with state-of-the-art, successful therapy. This inherent prejudice in favor of laser therapy is impossible to quantify.

In the two studies presented in the Journal 32 percent and 59 percent of the patients initially assigned to receive only medical treatment were crossed over to transmyocardial revascularization. Frazier et al. state that "crossover was allowed as an incentive for patients assigned to maximal medical therapy to remain in the study if medical therapy failed," which implies a bias on the part of investigators that transmyocardial revascularization was more effective than medical therapy.

If transmyocardial revascularization had been thought to be less effective or to be associated with greater morbidity than medical treatment, it would not have been offered as an enticement for patients to remain enrolled. The effect of such a bias may be substantial in a study in which the administration of therapy is not blinded and the crossover of patients is allowed if a subjective end point (in this case, angina) is reached. When the patient or the physician believes that the patient is not receiving the better therapy (transmyocardial revascularization), the likelihood increases that the alternative treatment (medical therapy) will be declared a failure. In short, the success or failure of antianginal medical therapy is a subjective assessment.

Before the use of transmyocardial revascularization is embraced enthusiastically, objective evidence of its efficacy should be strong. Unfortunately, there is little objective evidence that the results of transmyocardial revascularization are superior to those of medical therapy in patients with severe angina. In the study by Allen et al., the patients treated with transmyocardial revascularization had better exercise tolerance 12 months after enrollment than those treated medically. However, exercise tolerance was measured in fewer than one third of the patients and was not measured before enrollment to establish that the two groups were similar in this respect. In the single study in which exercise tolerance was assessed routinely at enrollment and at 12 months, transmyocardial revascularization was not associated with improvement.

In all three trials, myocardial perfusion was assessed at rest and during stress before and at various times after enrollment. In two of the three trials, transmyocardial revascularization did not improve myocardial perfusion, and in the third, the magnitude of the improvement in symptoms was disproportionate to the improvement in perfusion. Finally, in none of the three studies was transmyocardial revascularization associated with an improvement in left ventricular systolic function or survival one year after enrollment. Aside from a potentially marked placebo effect, how might transmyocardial revascularization improve angina?

Several mechanisms have been proposed, including proliferation of new blood vessels ("angiogenesis"), denervation of ischemic myocardium, and infarction of ischemic myocardium. In experiments in animals, transmyocardial revascularization induced a highly disorganized pattern of neovascularization at the periphery of laser-created channels that had occluded, a nonspecific response similar to that observed in any scar tissue.

Although it has been suggested that neovascularization may improve myocardial blood flow and thereby alleviate angina, the evidence that transmyocardial revascularization improves perfusion of ischemic myocardium is inconsistent and unpersuasive. Improved perfusion of ischemic myocardium achieved by traditional revascularization techniques often leads to improved left ventricular systolic function.

However, transmyocardial revas-cularization does not alter global or regional left ventricular performance. In studies in dogs, transmyocardial revascularization destroyed cardiac nerve fibers. If this effect occurs in patients, it may explain (at least in part) why myocardial ischemia is often painless in the immediate postoperative period. If, in fact, transmyocardial revascularization compromises the warning system, the advisability of using this procedure is questionable.

Finally, perfusion imaging in patients treated with transmyocardial revascularization has not shown a substantial increase in fixed perfusion defects, a change that could suggest the presence of procedure-induced myocardial infarction. However, currently available imaging techniques are not sufficiently sensitive to allow the detection of small laser-induced infarctions. After transmyocardial revascularization, the results of enzymatic tests reveal evidence of myocardial necrosis.

Transmyocardial revascularization is not a risk-free procedure. In the initial observational studies, perioperative mortality was 10 to 20 percent, and it was even higher among patients with severely depressed left ventricular ejection fractions, recent myocardial infarctions, or unstable angina. When such patients are excluded, perioperative mortality is about 5 percent. Perioperative morbidity is considerable: 32 to 68 percent of patients in the current randomized trials had at least one complication (nonfatal myocardial infarction, congestive heart failure, arrhythmia, or wound or respiratory infection).

In addition, the cost of transmyocardial revascularization is likely to be substantial, since the procedure requires expensive laser equipment, operating-room time and staff, the services of a cardiothoracic surgical team, and a relatively long hospital stay.

Finally, transmyocardial revascularization is not the only therapeutic option for patients with severe coronary artery disease that is not amenable to traditional revascularization techniques. Recently, novel noninvasive therapies, such as neurostimulation and external balloon counterpulsation, have been shown to improve symptoms and exercise tolerance in such patients.

These treatments are associated with lower rates of morbidity and mortality than is transmyocardial revascularization.

L. David Hillis, M.D.,
Richard A. Lange, MD
Univ. of Texas Southwestern Medical Center Dallas, TX 75235-9047
The New England Journal of Medicine -- September 30, 1999 -- Vol. 341, No. 14

Contributed by Myrna Porter,
Woodbridge, VA
with special effort - thanks, Ed.

The Organ King -

An outfit with life-and-death power over patients waiting for transplants has evolved into a heavy-handed private fiefdom.
By Brigid McMenamin, Forbes Magazine, Nov. 1999

EVER SINCE FORBES EXPOSED THE federal monopoly that's chilling the supply of transplantable organs and letting Americans who need them die needlessly (FORBES, Mar. 11, 1996), Health & Human Services Secretary Donna Shalala has been trying to challenge the way United Network for Organ Sharing operates.

But the Richmond, Va.-based cartel will have none of it. Using a heavy-handed mix of litigation, lobbying and bullying of its opponents, UNOS has solidified its position as the federal contractor in charge of deciding which people get new kidneys, livers or hearts.

Under the UNOS system, most organs are shared only within 62 regional territories. A potential recipient in, say, New York, where donations are low, can expect to wait months for an organ to show up, even though there may be so many donors across the river in New Jersey that New Jersey patients are getting transplants after short waits or when they are far from desperate.

Though UNOS has begun to relax the locals-first policy, still, last year 4,855 Americans died while waiting for transplants. (This doesn't even count people pulled off the list after they became too sick to handle a transplant.) It is a matter of debate how much lower the number of deaths would be if the system for obtaining and allocating organs were more rational. But Consad, a research outfit in Pittsburgh, estimates that at least 1,000 people die needlessly each year.

When Shalala urged that organs be shared over wider regions, UNOS Executive Director Walter K. Graham refused. He decreed, in a memo to his member hospitals and organ banks, that UNOS doesn't have to take direction from the federal government on this point. UNOS' main source of funding is the $375 registration fee potential organ recipients must pay to get on the waiting list. That amounts to some $13 million a year, money that is supposed to be spent mostly to match organs with suitable recipients.

In reality, at best half of the money goes to that. What about the rest? Graham and his 40 board members spend some $1 million each year on jetting around and on meetings and conferences. A new $7 million headquarters building is planned. In 1997, some $1.6 million went for items network officials refuse to explain.

"They really never tell you what they're spending money on," says veteran board member John Fung, a liver surgeon at the University of Pittsburgh.

When Shalala tried to exert more control over the rising registration fees, Graham challenged her in a proceeding before the U.S. General Accounting Office, claiming she had no right even to know how he spent the fees. The suit was settled; Shalala backed down. Why not simply bring in another contractor to ration organs? Good luck. The congressional committee in charge of such matters is headed by Representative Thomas Bliley, from UNOS' home city of Richmond. His cousin Paul S. Bliley is a law partner of UNOS lawyer Malcolm E. (Dick) Ritsch. Last fall, then-Louisiana Congressman Robert Livingston, whose home state includes eight profitable transplant centers, pushed through a bill halting further attempts by Shalala to control the contractor.

After the Senate rejected this moratorium, Livingston got it tacked onto another bill behind closed doors by threatening to hold up funding for the International Monetary Fund. The moratorium ends Oct. 21. But UNOS has already had Wisconsin Congressman David Obey tack another one-year extension onto a bill that was set to go to the full House for a vote in October. His state's four transplant centers stand to lose organs if UNOS loses its grip. UNOS milks desperate patients to subsidize a stealth for-profit firm.

Craig Howe, executive director of the National Marrow Donor Program, recently expressed interest in having his organization bid on the organ contract. After UNOS found out he was interested, his board members, who include 14 physicians, axed him.

Although some powerful and prominent surgeons like Fung are an exception, most doctors involved in the business fear offending UNOS lest their organ supply be affected. In another instance FORBES is aware of, UNOS threatened to retaliate against an outfit it perceived as a rival bidder for the organ allocation job.

Tax-exempt groups like UNOS are supposed to make their financial statements available for public perusal. But UNOS hides significant activity behind two little-known affiliates that aren't required to disclose anything. The first is the UNOS Foundation, a six-year-old shadow organization run by UNOS staffers. Spokesman Robert Spieldenner claims the foundation doesn't have to file tax returns because it brings in less than $25,000 a year.

The UNOS Foundation owns something called the Transplant Informatics Institute, a for-profit company run by organ network staffers. Transplant Informatics is so secret that even some UNOS board members are unaware that it exists. What does the institute do?

The government thinks it markets UNOS-developed software to organ network members. In an audit looking into the use of registration fees for lobbying, the Office of the Inspector General got just that impression. What the institute really does is analyze and sell organ network data to profit-making companies like Fujisawa, the Japanese firm that sells drugs for transplant patients. When the institute has not been able to cover its costs with such sales, UNOS has used its registration fee income to make up the difference.

Prospective organ recipients are therefore effectively funding this hidden business.

You'd think someone on UNOS' board would scream bloody murder about all this. After all, the 40-person board is almost half doctors, dedicated to saving lives. But the directors have little idea what's going on.

"The board is kind of in the dark," sighs patient advocate Charles Fiske, a former board member.

"We received an annual financial report and pretty much accepted it as written," says University of Oklahoma transplant doctor Larry R. Pennington, a board member from 1996 to 1998. They really don't know how to interpret the data.

"All I'm familiar with is hospital sort of activity," admits transplant physician William Harmon.

Realizing that UNOS is out of control, Shalala has put out feelers for a replacement.

"I hope we have some bidders this time," sighs Claude Fox, a pediatrician who, as administrator of the Health Resources & Services Administration oversees transplants for Shalala.

The only prospect so far is Santa Monica-based Rand. Determined to see that Rand does not walk off with the contract, UNOS' lobbyists are pushing for a law that would insure that Graham's group will keep the contract forever. Last month Bliley's committee held hearings on a bill which would require the organ rationing contractor to have experience, something no group but UNOS has.

It would also allow UNOS' members to vote on the choice. "Anything that gives them more of a stranglehold isn't in the public interest," says Fox. "It's like giving the EPA to some landfill company," says Dr. Fung.

It would be nice if UNOS didn't have a lock on this business. Better still if the federal government stepped out of the process altogether and let doctors come up with creative ways to increase the supply of organs.

(How about giving people who sign up as potential donors when they are young some priority in getting organs when they are older?) Once there are enough hearts and livers to go around, there won't be unaccountable arbiters holding sway over our lives.

Contributed by Tx David Cannavo, Lawrence, MA


The message that I tried to send to UpBeat readers last month seems to not have been worded as well as it might have been. The result has been sort of an opinion poll as to whether Upbeat should be continued. That's fine, and the support and kind words are most gratifying, but so far the vocal majority have been those who have always regularly demonstrated that they are sincerely interested. As yet the decision whether to continue has not been made, but it is beginning to appear that a middle ground may develop whereby those who haven't made contact in say 3 years will quickly and silently disappear from the mailing list without further ado as of 12/31/99. This will be only a partial solution and in fact may end up being a "clean shot to the foot" as the printer can't really make a major reduction in costs just because there are 100 less copies to print. So, one more time, if you haven't indicated your support of Upbeat since '97 we will probably be saying "good luck and stay well" as we wave good-bye at year-end.

Now here's a bit of what can be called "Support Group Medicine". Often since transplant it has been pointed out to me that I allow myself to become dehydrated, ergo - Don, you should drink more water. Early this year I was suffering symptoms of severe debilitation including extreme shortness of breath and being unable to sleep well. Blood tests were run and again all they really showed was rather severe dehydration. Now I do have a mild excuse. Since I lost my salivary glands to radiation therapy, I find that once one gets a satisfactory mix of the artificial saliva replacements in the mouth, one is not eager to wash it out by drinking water - the worst substitute for saliva there ever will be. But in deference to my kidneys, etc. I started slugging down water in the copious amounts of those people you see carrying water bottle with them. The effect was amazing, and first noted in the ability to sleep soundly (between trips to the bathroom). Shortness of breath problems weren't eliminated, but they sure improved as shown by my anecdotal level of difficulty recorded on the exercises at cardiac rehab. Yes, long story about a simple thing, but I'll bet patients often overlook it.

In October the success/failure statistics were published on all the transplant centers in the United States. The list is too long for inclusion here. However, as is usual in these times, all the data can be found on the Net at www.unos.org

And for one more year, you all please have the happiest of holiday seasons and a very healthy New Year. And be sure and remember all transplanted hearts should be checked for the Y2K compliance of the M162B chip inserted at the graff point right next to the check valve. Transplanted lungs only need to be checked for full inflation just after midnight of New Year's eve.

Later- Don M.



UNOS Responds To Forbes Article

October 28, 1999

NOTE: The following is adapted from a letter sent to Forbes senior management in response to a recent Forbes magazine article about UNOS.

The November 1, 1999 Forbes magazine article entitled, "The Organ King," written by Brigid McMenamin, intentionally disregards the truth and is full of malicious intent.

Ms. McMenamin deliberately mischaracterizes a member services fee that UNOS charges its institutional members for services provided to them. This fee is vital since the government contract only pays directly for roughly 11% of what it takes to operate the national network. The article states, "UNOS' main source of funding is the $375 registration fee potential organ recipients must pay to get on the waiting list," and "UNOS milks desperate patients to subsidize a stealth for-profit firm?' UNOS does not receive any funds from patients (and never has) and the Transplant Informatics Institute is far from being a "stealth" organization. This was explained to both Ms. McMenamin and a Forbes fact checker. Unfortunately, they ignored the truth.

Ms. McMenamin insinuates that UNOS' charitable funding is spent inappropriately on luxury and perks when she states, "What about the rest? Graham and his 40 board members spend some $1 million each year on jetting around" In fact, as a national policy-making organization, UNOS conducts more than a hundred national meetings annually, involving more than 300 people who volunteer their time and expertise to UNOS committees and the UNOS Board of Directors. All of these meetings involve efforts to enhance organ availability and establish responsible organ allocation policy. UNOS' travel policy, which is on the UNOS Web site, requires that all travel paid by UNOS be at commercial rates for coach class, and UNOS' in-house travel agency books all flights to minimize expenses.

Forbes has libeled UNOS egregiously by accusing UNOS of"bullying of its opponents" and stating that that the executive director of the National Marrow Donor Program (NMDP) was fired "after UNOS found out he was interested" in "having his organization bid on the organ contract." Ms. McMenamin never informed UNOS of this allegation; however, a Forbes fact checker indicated that the article would contain such an allegation and was told in a strong manner that the assertion was false. Unfortunately, Forbes intentionally disregarded the truth. Furthermore, UNOS has never threatened anyone with retaliation for bidding against UNOS. Ms. McMenamin's assertion is flagrantly untrue and when asked by UNOS to provide a specific example of this allegation, Ms. McMenamin refused.

It is painfully obvious that Ms. McMenamin has not taken the time to understand how UNOS works. An excellent example is her statement, "Better still if the federal government stepped out of the process altogether and let doctors come up with creative ways to increase the supply of organs." That is the whole concept of UNOS. Volunteers from the transplant community, including doctors, nurses, medical professionals, patients and donor families, come together through UNOS in cooperation with the U.S. Department of Health and Human Services to operate the nation's organ transplant system.

Another mystifying statement is that physicians "fear offending UNOS lest their organ supply be affected." UNOS is operated by its members, through a nationally elected, volunteer Board of Directors, which includes physicians, patients and organ donor family members. The Board makes all major decisions. UNOS members initiate all policy proposals and are always represented in any policy decision or substantive action undertaken through the consensus of the Board of Directors. The executive director follows the Board's directives. Everyone has an idea how organs could best be allocated. Fortunately, UNOS is where constructive policy is openly debated and the answer emerges. The process is highly participatory. UNOS, a private sector organization, is more open and accountable than any government agency.

UNOS welcomes responsible comments and criticisms of its operation, however Ms. McMenamin's blatant disregard for the truth makes "The Organ King" a perfect example of what journalism should not represent. Unfortunately, Ms. McMenamin's article has probably damaged more than the reputation of UNOS and Mr. Graham. There is the possibility that this very inaccurate and misleading article could keep someone from deciding to be an organ donor. That could be the very real consequence of Ms. McMenamin's irresponsible reporting.

UNOS has demanded a retraction and a written apology from Forbes. We have also invited the magazine to send an unbiased professional to UNOS to see how it truly operates.

"In the back of your mind was always the thought that if any scandal was brewing it would be the glamorous ex-model who ran off with a younger man, leaving Chris with crippled hands, a flagging libido and haunting memories of all the film stars and lovelies he'd bedded during his life," wrote author Rian Malan. "How different it turned out to be."

An irate Barnard -- who suffers from arthritis in his hands -- telephoned the editor and demanded a retraction, but the magazine is standing by its story.

"We have written to Fair Lady and advised them of our client's concerns and have reserved our right to take further action," Catto told Reuters.


The divorce battle is the latest turn in a life that has had all the ingredients of a best-selling novel.

Born the son of a missionary in the dusty farming town of Beaufort West, about 300 miles from Cape Town, Barnard wanted to be an engineer. But he took his brother's advice and went into medicine because it paid better.

After studying surgery at the University of Minnesota, a young Barnard returned to Cape Town's Groote Schurr hospital and honed his skills in open-heart surgery.

On Dec. 3, 1967, he sliced open the chest of Louis Washkansky, a 55-year-old grocer, and replaced the dying man's heart with a healthy organ taken from a young woman who had died in a car accident.

"We didn't take a single picture of the operation. I didn't even phone the hospital to tell them that we were doing it. All the media attention was a tremendous surprise," Barnard told a Canadian journalist in a rare interview last year.

Washkansky lived for only 18 days, but the operation made Barnard a global celebrity at age 45, courted by presidents, kings and the international jet set.

In a 1993 autobiography, Barnard revealed how he was "consumed and intoxicated" with fame after the operation.

His face adorned the cover of Time and other international magazines, television networks scrambled for interviews, and the Guinness Book of Records once claimed he received more fan mail than anyone on earth.

The handsome surgeon enjoyed a playboy existence, partying with the likes of Sophia Loren, Audrey Hepburn and Richard Burton, and meeting the pope and world leaders such as Lyndon Johnson and Indira Ghandi.

Barnard's appetite for the good life was insatiable and his fame attracted a bevy of beautiful women. Affairs with Italian film stars Loren and Gina Lollobrigida led to a divorce from his first wife, Louwtjie, mother of his first two children.

In 1970 he married a 19-year-old heiress, Barbara Zoellner, but she eventually left him after their house maids told Zoellner her husband was fooling around. He hired a witch doctor to put a hex on the maids and vowed never to be tied down again.

But when Barnard reached his late 50s he fell in love with a young Setzkorn, married her and began raising a new family. Asked last year if he was tempted by beautiful women any more, Barnard replied: "Well, no. I'm also older, you know."


Barnard has said his big regret was turning away a Hollywood agent at the height of his fame and not cashing in.

After 25 years as a professor and surgeon, he retired in 1983 with a small pension after performing 75 transplants. Barnard wrote several books, including a medical thriller called The Donor, but they didn't sell well.

His hatred of aging led to an embarrassing association with an American company in the mid-1980s that used his name to sell unproven anti-aging cream.

Recently, South African movie goers have seen the famous surgeon serve as pitchman for a four-wheel-drive car.

Business ventures and the lecture circuit, where he earns about $10,000 a speech, continue to take him abroad. But he also retumed to his roots in the Karoo desert last year when he opened the Chris Barnard Game Lodge.

"I'd be happy to share some of my memories of the world's first heart transplant with you," says Barnard in lodge pamphlet. "I've yet to meet the person who doesn't find it a remarkable and entertaining story!"

And Now From the UpBeat Enquirer Edition

Affairs Of The Heart Follow Famed Doctor

By Darren Schuettler

JOHANNESBURG, South Africa (Reuters 9/21/99) - An affair of the heart has thrust the world's most famous cardiac surgeon, Dr. Chris Barnard, into the spotlight again --three decades after he performed the first human heart transplant.

The 76-year-old doctor-turned-playboy, one of the more famous South Africans of this century, is embroiled in a divorce battle with his third wife that has grabbed headlines countrywide.

Karin Setzkorn, a 35-year-old former model, has filed for divorce claiming an "irretrievable breakdown" of their 11-year marriage.

"Obviously he is very distraught and distressed and upset by what has happened," says Barnard's lawyer, Amanda Catto. "She's seeking relief and we will defend (against) the relief."

Setzkorn claims she found Viagra, the miracle drug for men whose virility has seen better days, and condoms in his toiletries bag and concluded he was having an affair. She also accuses Barnard of humiliating her by flirting with other women.

Aside from facing his estranged wife in court, Barnard has threatened legal action against a women's magazine, Fair Lady, for an unflattering profile in its September issue.

NZ Hand Transplant Man Probed For Fraud In France LYON, France

(Reuters 10/11/99) - A New Zealand man who made medical history last year when he received the world's first hand transplant in France was put under police investigation for fraud Monday when he returned for a check-up.

Police accused businessman Clint Hallam of using the details of a French friend's credit card to pay hotel and telephone bills and making off with money the two had collected to help other people with transplanted organs, a Lyon judge said.

Now barred from leaving Lyon, where he was given a new right hand in September 1998 to replace one cut off in an electric saw accident in 1984, Hallam will have to face his accuser on Wednesday, said judge Stephan Noel.

A team of surgeons from France, Australia, Britain and Italy attached the hand and forearm of a brain-dead patient to Hallam's amputated arm in a 13-1/2 hour operation.

Doctors said the biggest risk was that Hallam's body would reject the new hand, but powerful new drugs appear to have brought his immune system under control. Hallam, 49, who lives in Perth, Australia, was accused of fraud back home when former associates saw him on television talking about his transplanted hand.

"Organs Watch" To Track Human Organ Traffic

By Andrew Quinn

SAN FRANCISCO, (Reuters 11/4/99) -U.S. researchers announced Thursday the launch of a new group to monitor trafficking in human organs, the grisly but profitable trade in body parts that now stretches around the world.

"Organs Watch," based at the University of California at Berkeley, will check reports and rumors of human rights abuses in organ trafficking, identify areas where abuse may be occurring and begin to define the line between ethical transplants and practices that are exploitative or corrupt.

"Transplant surgery has entered a global market and we need to keep a close watch on that," said Nancy Scheper-Hughes, a associate professor of anthropology who helped to found the group. "In the organs trade business, abuses creep in before you know it."

The new center, funded by a two-year grant of $230,000 provided from the Soros Foundation's Open Society Institute and an additional $160,000 from the university, will compile reports from transplant surgeons and other medical people from at least a dozen countries and act as a clearinghouse for transplant-related information.

It will also sponsor research into reports of transplant abuse, and lobby to strengthen national and international laws governing trade in human organs.

The researchers and medical ethicists involved with the new group say human organ trafficking has exploded in recent years, due in part to the rapid spread of medical transplant technologies once found only in the most advanced hospitals of the developed world.

In almost all cases the poor are providing body parts for the rich.

Lawrence Cohen, a Berkeley professor of anthropology, found that in parts of India known as "the kidney belt," poor people regularly use their kidneys as collateral for money lenders who have come to expect desperate people to sell their body organs to seal a deal.

"Most sellers would say, 'I'd do it again. I have a family to support. What choice did I have?"' said Cohen.

Elsewhere, in police mortuaries in South Africa, eyes, heart valves and pineal glands from the corpses of the poor have been "harvested" without family consent and later appear at local transplant clinics, Scheper-Hughes said.

And China has faced persistent accusations -- all vehemently denied by the government -- that authorities take the organs of executed criminals, and that executions are timed to meet the country's need for replacement livers, hearts and kidneys.

Scheper-Hughes said that while selling or harvesting human organs is illegal almost everywhere in the world, in many cases local enforcement is lax and wide loopholes exist.

"We need more research, and we need to get more of this out on the table," she said.

"Transplant surgery is so secret, and the doctors have so much authority, in many countries it's the doctors who control what is going on."

A Web site called "medicine, markets, and bodies," with information on the new group can be found at http:// yana.sscl.berkeley.edu/orgwatch.

BARRON'S: Editorial Commentary- Organ Market? Put A Price Tag On Scarce Resources

By Thomas G. Donlan

Waiting lists with hundreds of patient names attest simultaneously to the practicality of transplanting hearts, livers, kidneys, retinae and other organs and to the difficulty of obtaining enough for transplant.

People are cut down in the prime of life by car accidents and other muses of violent death, but many don't provide for organ donation.

There's no need to speculate on the reason for the shortage of donors. Altruism is generally in short supply, but the National Organ Transplant Act of 1984 prohibited transactions in organs. Although a (possibly fraudulent) eBay auction of a kidney drew bids up to $5.7 million before it was shut down, donation is the only legal means of transferring human organs.

Some states have tried to encourage organ donation by letting people check a box on their drivers' licenses. Earlier this year, Pennsylvania went further, starting a program to skirt the federal law, encouraging organ donation by paying $300 toward funeral expenses for persons whose relatives authorized organ donation.

It's too little, too late. The Organ Transplant Act's prohibition on trade in organs should be modified. Non-profit organizations representing potential organ recipients should be allowed to pay people for signing organ donation contracts. There's no use pretending that organs don't have value, and much good to be done by recognizing that they do.

Disclaimer: The material in this document has been collected by Don Marshall and friends. New ideas and materials are welcome all the time. Nothing herein is ever to be construed as medical advice. As a policy, UpBeat is sent upon request to heart and heart/lung transplant recipients and other interested parties. Donations of $15 per year, or more, from Tx recipients, if not a burden, are vital. From all others the donation is specifically requested. The date shown after the name on the address label indicates the last time a donation was received. Please make checks payable to Don Marshall, as we cannot afford to become nonprofit. Send materials, letters, or checks to:

Don Marshall
P.O. Box 482
Mathews, VA 23109-0482
Compuserve 74016,1725
FAX 804-725-3686
Internet: donmarsh@visi.net