A 78-year-old man who presented with heart failure underwent percutaneous coronary intervention (PCI) for severe stenosis in the right coronary artery ( Fig. 1 A ). Optical frequency domain imaging (OFDI) showed a protruding mass in the lesion, suggestive of a calcified nodule (CN) ( Fig. 1 B). Orbital atherectomy (OA) with the Diamondback 360® coronary OA system (Cardiovascular Systems, St. Paul, MN) at low speed (80,000 rpm) was performed for CN ablation, which caused a minor injury of the healthy side of the vessel wall ( Fig. 1 C). Since additional OA might have led to coronary perforation, we switched to lesion modification using a 3.0-mm scoring balloon (NSE Alpha; Goodman, Nagoya, Japan). OFDI after balloon dilatation showed a change in the position of the guidewire relative to the score within the CN, which allowed us to perform more aggressive debulking safely ( Fig. 1 D). After additional low-speed OA, OFDI confirmed successful ablation ( Fig. 1 E). Further OA at high speed (120,000 rpm) resulted in substantial CN debulking ( Fig. 1 F). The lesion was dilated with a non-compliant balloon followed by a paclitaxel-coated balloon (SeQuent Please; B Braun, Melsungen, Germany). Final angiography showed a well-opened lumen ( Fig. 1 G).