88 year old female with prior BMS in proximal LAD in 2010, presented with worsening dyspnea on exertion (NYHA class III) and mild chest pressure for few months. A recent echo revealed a fall in LVEF from 55% in 2010 to 22% now. A Cardiac Cath on November 28, 2017 revealed heavily calcified II vessel and 80% Left main bifurcation disease involving proximal LAD (patent BMS) and ostial circumflex, SYNTAX score of 24 and LVEF 26%. IVUS revealed distal LM MLA of 5.2 mm2 with significant prox LAD and moderate ostial circumflex disease. Patient was optimized on heart failure and anti-ischemic medical therapy. A stress thallium MPI on November 30, 2017 revealed global ischemia and viability in anterior, inferior and lateral walls. Patient is now planned for IVUS guided Protected PCI of ULM bifurcation utilizing Rotational Atherectomy & Impella hemodynamics support and dedicated 2-stent technique.