56 year old diabetic male presented with angina equivalent dyspnea, left heart failure and a positive SPECT MPI for multivessel infarction (70%) and ischemia (30%). A Cardiac Cath on February 7, 2017 revealed 3 V CAD: total occlusion of mid RCA, total occlusion of mid LAD, 90% LCx-OM1 with SYNTAX Score of 28 and severe LV dysfunction LVEF 28%. Patient underwent cardiac MRI, which revealed subendocardial myocardial infarction of interior and inferolateral segments, transmural infarct involving apex and substantial viability of numerous myocardial segments. Patient underwent Heart Team discussion and CABG was declined due to diffuse CAD and patient’s preference for PCI. Patient has been optimized on guided medical therapy. Patient is now planned for protected multivessel PCI with Impella LV assist device.