BACKGROUND In recent years, a series of studies have investigated long-term outcome of rotational atherectomy (RA). However, only little attention was given to the procedural details of RA technique, especially with regard to platform speed. AIMS The aim of the study was to evaluate the impact of low-speed RA with substantial debulking before stenting on long-term mortality. METHODS A group of 356 patients with a high plaque burden underwent substantial debulking with RA with low platform speed of 135 000 rpm and was compared with a group of 553 patients treated without RA in the same time period. In both cohorts lesion preparation was followed by stent implantation. The endpoint was all-cause mortality up to 80 months with a mean (SD) follow-up of 49 (24) months. RESULTS Despite the fact that patients treated with RA were significantly older and presented more unfavorable lesion characteristics than non-RA patients, there was no significant difference in long-term survival between groups. A propensity analysis with 279 matched pairs showed that long-time survival in RA patients was better than in non-RA patients (hazard ratio, 0.52; CI, 0.32-0.85; P <0.01). CONCLUSIONS Substantial debulking with RA continues to play a role in the treatment of calcified coronary arteries. We hypothesize that RA with low platform speed and substantial debulking with a burr-to-artery ratio of up to 0.64 results in favorable long-time survival in patients with high plaque burden. However, this can only be proved in a prospective randomized trial.