I read with great interest Dr. Kini et al’s manuscript entitled ‘‘Changing outcomes and treatment strategies for wire-induced coronary perforations in the era of bivalirudin use’’ [1]. They concluded that major adverse cardiac events in patients with wire perforation (WP) occurred only in the heparin-treated arm and not in the bivalirudin group. They explained their results based on shorter bivalirudin half life. Their finding and explanation cannot be substantiated by pharmacology of theses drugs. Heparin can be immediately and completely reversed after administration of protamine without increasing risk of stent thrombosis [2]. No data is given about protamine use in patients with type II WP. Furthermore, three patients received GPIIb/IIIa inhibitors in heparin arm vs. only one in bivalirudin group. Complete heparin reversal without the use of GPIIb/ IIIa inhibitors should be much more effective in achieving normal coagulation status immediately in comparison to holding bivalirudin. Bivalirudin’s half life is 25 min [3,4]. Therefore, for an activated clothing time (ACT) of over 300 s, at least 60 min should require for complete normalization of coagulation. I have rarely seen patients who have an ACT of < 180 s for sheath removal less than 1 hr after bivalirudin discontinuation. There is no logical explanation why patients without GPIIb/IIIa inhibitors use and complete reversal of anticoagulation with protamine in heparin arm should have worse outcome in comparison to holding bivalirudin alone. The most likely explanation of their finding is probably a selection bias. It is standard of care to use heparin for lesions with high possibility of perforation requiring anticoagulation reversal. The use of high risk wires in each arm is not described in this manuscript. Hydrophilic and stiff wires are most likely to cause larger perforation in comparison to soft tip wires. To clarify this issue, the authors need to report the type of wires used in each arm and separate patients who received protamine for reversal versus patient without protamine administration. The author’s conclusion of ‘‘bivalirudin may offer a safer alternative for anticoagulation in complex PCI’’ should be read with extreme caution. Until larger controlled trials are available, the use of bivalirudin in patients at high risk for perforation such as total chronic occlusions should be avoided as immediate reversal of anticoagulation is not possible.