Routine thrombus aspiration in patients undergiong primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) does not improve clinical autcomes. The purpose of this study was to evaluate the benefit of thrombus aspiration among STEMI patients with high thrombus burden (thrombus grade 3 - 5) as a pre-specified subgroup from TOTAL Trial.