Heparin-induced thrombocytopenia (HIT) is an antibody-mediated reaction in which heparin administration causes a person to enter a pathological and highly prothrombotic state. When patients with known HIT undergo coronary artery bypass and grafting procedures, they must be appropriately anticoagulated. The dangers of heparin administration in this population necessitate the use of an alternative anticoagulant. The case describes the successful use of bivalirudin for procedural anticoagulation during an off-pump coronary artery bypass and grafting.