86 year-old male with chronic ischemic heart diease, prior MI and PCI in the remote past, presented with crescendo CCS Class III angina and chronic systolic heart failure. A stress MPI revealed large severe inferior wall defect with significant reperfusion. A Cardiac Cath on September 28, 2015 revealed multivessel calcific CAD; 80% distal LM bifurcation, 60% mid LAD and 80% D1, 95% LCx – LPL1 and CTO of LPDA with moderate-severe systolic LV dysfunction (LVEF 30%) and SYNTAX score of 39. After Heart Team discussion CABG was recommended, but patient refused any revascularization and went home. He continued to be symptomatic on maximal tolerable medical therapy. Patient is now planned for high risk PCI of calcific left main bifurcation with rotational atherecomy and Impella LV assist.