Introduction: Heavily calcified or fibro-calcified stenotic lesions have remained challenging for interventional cardiologists, especially in an acute coronary syndrome setting. Rotational atherectomy (rotablation, RA) of coronary artery is not so often used in high thrombotic state such as acute myocardial infarction (AMI) because of the risk of platelet activation by the rotablator. (1-3)

Case report: 51-year-old man with arterial hypertension and diabetes mellitus in his previous medical history presented with non-ST-segment elevation myocardial infarction. His GRACE score was 106 and the next day he underwent coronary angiography. Double vessel coronary artery disease was found with calcified significant stenosis of the left anterior descending (LAD) artery. His echocardiogram showed reduced systolic function of left ventricle, hypokinetic anterolateral wall with reduced global longitudinal strain (GLS). He was presented to the Heart team and the decision was made to do percutaneous coronary intervention (PCI) with RA to the LAD, due to calcified LAD in the area of lending zone for possible left internal mammary artery (LIMA) graft. The following day PCI with RA to LAD and PCI to first obtuse marginal branch (OM1) were done. The patient improved remarkably after the procedure, and was discharged after 3 days.

Conclusion: As known, calcified lesions could be found in 8% of patients with AMI, and one-quarter of them were balloon un-dilatable or un-crossable and the PCI is therefore difficult or impracticable. As seen, RA is safe method in acute coronary syndrome (ACS) when it is done by well-trained team experienced in complex PCI’s.