Aim To study the efficacy of rotational atherectomy (RA) versus balloon pre-dilated combined with drug eluting stent(DES) implatation in the treatment of heavily calcified coronary lesions. Methods The study selected patients with heavily calcified coronary lesions admitted in Fuyang City People's Hospital from October 2017 to October 2018 who were going to receive PCI. The patients were divided into two groups according to the random number table, which were the RA combined with DES group (observation group, n=32) and the balloon pre-dilated combined with DES(control group, n=40). Prospective randomized controlled study was performed. The treatment characteristics and perioperative complications were compared between the two groups. The risk factors of major adverse cardiovascular and cerebrovascular events (MACCE) within 6 months were analyzed. Results The average stent diameter was significantly higher in the observation group than in the control group (3.25 (3.0,3.50) mm vs 3.00 (2.1,3.25) mm, P=0.002). The number of balloon pre-dilated,pre-dilated maximum pressure, the number of balloon post-dilated and post-dilated maximum pressure were significantly lower in the observation group than in the control group(P＜0.05). The lumen diameter after PCI was significantly larger in the observation group than in the control group((3.34±0.28) mm vs (3.15±0.27) mm, P=0.005). The procedural success rate of the observation group (96.9%) was higher than that of the control group (92.9%), the incidence of total MACCE in the observation group (9.4%) was lower than in the control group (22.5%), but there is no significant differences between the two groups(P＞0.05). The previous PCI(risk ration:1.5,5%CI:0.030～0.691, P=0.015) and the maximum pressure of balloon pre-dilated(risk ration:2.6,5%CI:0.721～0.988, P=0.035) were independent risk factors for MACCE within 6 months. Conclusions For severely calcified coronary lesions with a SYNTAX score of 23 to 32, RA has tendencies to improve the procedural success rate and reduce short-term adverse events. The previous PCI and the maximum pressure of pre-dilated were independent risk factors for MACCE within 6 months.