77 year old male with known severe aortic stenosis, presented with NYHA and CCS Class III angina and dyspnea and a positive pharmacological MPI for inferior wall ischemia. A Cardiac Cath on December 18, 2017 revealed 3 V CAD: 95% calcified ostial RCA, 70% distal LAD, 70% diagonal, 60% proximal LCx with SYNTAX Score of 18 and LVEF 60%. Echo revealed mean aortic gradient of 55mmHg with AVA of 0.6 cm2. Heart Team discussion recommended PCI of RCA followed by TAVR after one month. Patient underwent rotational atherectomy (using 1.5, 1.75 and 2.15mm burrs) of the RCA ostial lesion followed by high pressure balloon dilatation, but ostial lesion could not expand, still 80% residual lesion. Patient is now planned for first the BAV and then high risk PCI using larger rota burr atherectomy followed by DES and Ostial Flash balloon inflation for ostial stent optimization.