Heparin induced thrombocytopenia presents as an underdiagnosed condition with life threatening thrombotic complications. The incidence in cardiac surgery patients is dependent on several factors and appeared to be greater in procedures that involve the use of intraaortic balloon pump. Clinical diagnosis is particularly challenging in cardiac surgery patients due to the natural occurrence of post-operative thrombocytopenia. High index of suspicion is key factor to establish adequate treatment and prevent the occurrence of thrombotic complications, such as saphenous vein graft occlusion, pulmonary embolism and myocardial infarction, which lead to substantially increased mortality rates. The 4T’s assessment point system was designed in order to evaluate the likelihood of occurrence of the condition based on clinical presentation; however, serotonin release assay represents the gold standard to reach diagnosis. Treatment of heparin induced thrombocytopenia involves cessation of unfractionated and fractionated heparin, and the instauration of therapy with direct thrombin inhibitors. Among all direct thrombin inhibitors agents, Bivaluridin is emerging as a potential first line of treatment based on its benefits of a short half-life and enzymatic elimination.