The authors thank Drs. Erdoes, Koster, and Levy for their very cogent and detailed analysis of our study. We agree with many of the points they made, specifically the very limited effect dabigatran has on coagulation due to its specificity for thrombin. Most would agree, however, if only one enzyme in the coagulation system can be inhibited, thrombin is the obvious choice given its central place in the coagulation cascade, and its many indirect effects via feedback loops as indicated by Erdoes et al. Furthermore, by far the largest published successful experience with any drug class as a substitute for heparin in cardiopulmonary bypass (CPB) is with direct thrombin inhibitors, particularly bivalirudin.3,4  We have previously shown that the anti-Xa agent rivaroxaban has a synergistic anticoagulant effect with dabigatran and this combination may prove to be a better substitute for heparin than a direct...

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