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Bring a large pot of salted water to a boil. Add the pasta and cook according to the package instructions until al dente. Reserve ½ cup of pasta water, then drain and set aside.
In a large skillet, melt the butter over medium heat. Add the minced garlic and sauté until fragrant (about 1 minute).
Reduce the heat to low, then stir in the heavy cream. Simmer gently for 2–3 minutes, allowing it to thicken slightly.
Stir in the pesto and Parmesan cheese, mixing until the sauce is smooth and creamy. Season with salt and pepper to taste.
Add the cooked pasta to the skillet and toss to coat it evenly in the creamy pesto sauce. If the sauce is too thick, add the reserved pasta water, a little at a time, until it reaches your desired consistency.
Plate the creamy pesto pasta and top with additional Parmesan cheese, fresh basil, and your choice of grilled chicken, shrimp, or roasted vegetables if desired.