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the optimal intervention in as is still controversial. performing tavr using a transapical access is associated with a significantly higher risk of mortality and morbidity than with transfemoral approach. therefore, it is strongly recommended to perform transfemoral tavr whenever possible. in the case of aortic valve stenosis associated with aortic regurgitation, the presence of as is associated with an increased operative risk. thus, in the case of low ejection fraction and severe symptomatic as, the patient should be treated by a team of experts to decide whether a tavr could be performed with satisfactory results. a number of guidelines, including the european society of cardiology guidelines, recommend tavr in patients with severe as and no surgical alternatives. this intervention can be performed through transfemoral or transapical accesses, and these accesses have different potential advantages and disadvantages. on the other hand, transapical access is preferred in patients with severe as, and has potential advantages over transfemoral access. however, tavr performed through a transfemoral access is associated with fewer complications than transapical access. the access site has an impact on outcomes. there are no randomized controlled trials comparing the two approaches, and the available data are insufficient to make a decision. the chas registry does not support a single preferred access approach, as its data do not allow us to determine if one approach is associated with a greater risk of complications. furthermore, it is not possible to identify the patients in whom the two approaches are equivalent. the chas registry was designed to determine if transapical tavr was associated with greater morbidity and mortality than transfemoral tavr. although this analysis was not performed in the chas registry, the reduction in mortality associated with transapical tavr is noteworthy. more than half of patients in the chas registry were referred to a center with a transapical access, and the observed mortality rate was lower than the rates reported in the main randomized trials. the overall early safety and efficacy of transapical tavr seem to be equivalent to those of transfemoral tavr. however, transapical tavr is associated with a greater risk of stroke than transfemoral tavr. moreover, some patients do not have access to the transapical approach due to anatomical characteristics, and there are no data on the outcomes of these patients. thus, the chas registry provides useful information on the safety and efficacy of the transapical access, and its impact on the clinical practice of the procedure.
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