There is no well-de ned reversal agent for bivalirudin, and patients with coagul- opathy and excessive bleeding require unusual in- terventions for hemorrhage control. Only anecdotal experience is available to address coagulopathy in cases of bivalirudin-related hemorrhage [68, 71]. Consensus suggests that a multifaceted approach offers the best chance of successful hemorrhage control for these pa- tients. Recombinant activated factor VII may be an important part of hemorrhage control but other in- terventions including modi ed ultra ltration, hemodialysis, and clotting factor replacement are also advocated [71]. References 1. Stoney WS. Evolution of cardiopulmonary bypass. Circu- lation 2009;119:2844 53. 2. Ferraris VA. Heroes and evidence. J Thorac Cardiovasc Surg 2002;124:11 3. 3. Bull BS, Korpman RA, Huse WM, Briggs BD. Heparin therapy during extracorporeal circulation. I. Problems inherent in existing heparin protocols. J Thorac Cardiovasc Surg 1975;69:674 84. 4. Young JA, Kisker CT, Doty DB. Adequate anticoagulation during cardiopulmonary bypass determined by activated clotting time and the appearance of brin monomer. Ann Thorac Surg 1978;26:231 40. 5. Na S. Stabilized infective endocarditis and altered heparin responsiveness during cardiopulmonary bypass. World J Surg 2009;33:1862 7. 6. Garvin S, FitzGerald DC, Despotis G, Shekar P, Body SC. Heparin concentration-based anticoagulation for cardiac surgery fails to reliably predict heparin bolus dose re- quirements. Anesth Analg 2010;111:849 55. 7. Grima C. The effects of intermittent prebypass heparin dosing in patients undergoing coronary artery bypass grafting. Perfusion 2003;18:283 9. 8. Neema P, Sinha P, Rathod R. Activated clotting time during cardiopulmonary bypass: is repetition necessary during open heart surgery? Asian Cardiovasc Thorac Ann 2004;12: 47 52. 9. Shore-Lesserson L. Evidence based coagulation monitors: heparin monitoring, thromboelastography, and platelet function. Semin Cardiothorac Vasc Anesth 2005;9:41 52. 10. 