59 year-old male with prior BMS PCI in 1/2003, now presented with CCS Class II angina and high risk stress MPI for moderate to severe ischemia in 3 vessel distribution and severe dilated LV with TID. A Cardiac Cath on August 5, 2014 revealed II vessel + LM CAD with severe LV systolic dysfunction (LVEF 28%); CTO distal RCA, 70% distal left main, 80% ulcerated in-stent restenotic lesion in mid LAD and 70% D2 with SYNTAX Score of 34. Heart Team consultation was done and CABG declined strongly by the patient’s preference. Patient underwent successful PTCA and DES to distal RCA and RPDA without any complications. Patient is now planned for OCT guided staged PCI of ULM and LAD with Impella assist for LV support.