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Background: The relationship between changes in the left atrial volume index (LAVI) post-catheter ablation (CA) and long-term prognostic events in patients with persistent atrial fibrillation (AF) remains unclear. We evaluated the incidence of major adverse clinical events (MACE), including all-cause death, unplanned heart failure hospitalization, and unplanned cardiovascular hospitalization using pre- and post-CA LAVI., Methods and Results: We collected data retrospectively from 150 patients with persistent AF who underwent their first CA. LAVI was calculated during preprocedural echocardiography under AF rhythm (pre-CA LAVI) and 3 months post-CA under sinus rhythm (post-CA LAVI). The cumulative incidence of MACE was compared among 3 subgroups based on the cutoff values of pre-CA (45.5 mL/m 2 ) and post-CA (46.5 mL/m 2 ; both determined using the c-statistic) LAVI. The subgroup of a pre-CA LAVI >45.5 mL/m 2 with a post-CA LAVI >46.5 mL/m 2 (n=45) had a significantly higher MACE incidence compared with other subgroups (P=0.002). Multivariate analysis identified this subgroup as independently at higher risk for MACE. The subgroup of a pre-CA LAVI >45.5 mL/m 2 with a post-CA LAVI ≤46.5 mL/m 2 (n=49) had an incidence comparable with those with pre-CA LAVI ≤45.5 mL/m 2 (n=56) and exhibited a significantly greater reduction in LAVI than other subgroups did (P<0.001)., Conclusions: Combining pre-CA and post-CA LAVIs is valuable in stratifying long-term MACE development risk following CA., Competing Interests: The authors declare that there are no conflicts of interest. This research received no grants from any funding agency in the public, commercial, or not-for-profit sectors. M.S. is a member of the Editorial Board of Circulation Journal/ Circulation Reports., (Copyright © 2024, THE JAPANESE CIRCULATION SOCIETY.)