86 year-old-male with mechanical aortic valve prosthesis and prior PCI’s of LAD and RCA presented with crescendo leading to rest angina. Cardiac Cath on July 7, 2014 revealed 90% calcific distal left main bifurcation lesion with patent prior stent sites. Echo revealed LVEF 50% and normal functioning aortic prosthesis. CABG recommended but declined due to age and re-do surgery. Patient is now planned for PCI of heavily calcified unprotected distal left main lesion, using atherectomy and two stent strategies and possible IABP assist.