Citation Nr: 1618737 Decision Date: 05/10/16 Archive Date: 05/19/16 DOCKET NO. 10-18 491 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a recurrent heart disorder, to include coronary artery disease (CAD) and coronary artery bypass graft (CABG) residuals, to include as secondary to medications taken for service-connected osteoporosis. 2. Entitlement to compensation under the provisions of 38 U.S.C.A. § 1151 for recurrent Methicillin-resistant Staphylococcus aureus (MRSA) infection residuals. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD D. Van Wambeke, Counsel INTRODUCTION The Veteran served on active duty from July 1981 to March 1983. These matters come to the Board of Veterans' Appeals (Board) on appeal from a June 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the claims in June 2014 for additional development. The current record before the Board consists entirely of electronic files known as Virtual VA and the Veterans Benefits Management System (VBMS). FINDINGS OF FACT 1. The probative evidence weighs against a finding that the Veteran's recurrent heart disorder, to include CAD and CABG residuals, had its onset during active duty service or within one year of the Veteran's March 1983 discharge from active duty service, or that a recurrent heart disorder, to include CAD and CABG residuals, is related to such service; and no probative evidence establishing that the Veteran's recurrent heart disorder, to include CAD and CABG residuals, is proximately due to, or a consequence of, medications taken for service-connected osteoporosis. 2. An additional disability was not caused by carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA, and any additional disability was an event reasonably foreseeable. CONCLUSIONS OF LAW 1. The criteria for service connection for a recurrent heart disorder, to include CAD and CABG residuals, have not been met. 38 U.S.C.A. §§ 1101, 1131, 1137, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2015). 2. The criteria for entitlement to compensation under the provisions of 38 U.S.C.A. § 1151 for recurrent MRSA infection residuals have not been met. 38 U.S.C.A. §§ 1151, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303(c), 3.361, 4.9 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act Under the Veterans Claims Assistance Act of 2000 (VCAA) VA has a duty to notify and assist a claimant in the development of a claim. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2015). The notice requirements of the VCAA require VA to notify a claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2015). Compliant VCAA notice was provided in August 2006 and January 2007, prior to the June 2007 promulgation of the claims in the first instance by the agency of original jurisdiction. In addition, the Board finds that the duty to assist a claimant has been satisfied. The Veteran's service treatment records are on file, as are various post-service medical records, to include records obtained from the Social Security Administration. In addition, VA examinations have been conducted and opinions obtained. The Board also notes that actions requested in the prior remand have been undertaken. More specifically, the Veteran was asked to provide information as to all treatment of his CAD, CABG residuals, and recurrent MRSA residuals and the addresses of all health care providers whose records had not already been provided to VA; VA clinical documentation pertaining to the treatment of the Veteran not already of record, to include the Veteran's signed consent to the September 2004 CABG surgery and that associated with treatment provided after 2007 were obtained; SSA records were obtained; and VA medical opinions were obtained. Accordingly, the Board finds that there has been substantial compliance with the prior remand instructions and no further action is necessary. See D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)). The Board notes that the Veteran did not respond to an August 2014 letter seeking information as to health care providers whose records had not already been obtained. After a careful review of the file, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C.A. § 1131. Service connection may also be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish service connection for a disability resulting from a disease or injury incurred in service, or to establish service connection based on aggravation in service of a disease or injury which pre-existed service, there must be (1) competent evidence of the current existence of the disability for which service connection is being claimed; (2) competent evidence of incurrence or aggravation of a disease or injury in active service; and (3) competent evidence of a nexus or connection between the current disability and the disease or injury incurred or aggravated in service. Horn v. Shinseki, 25 Vet. App. 231, 236 (2010); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009); cf. Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). In many cases, medical evidence is required to meet the requirement that the evidence be "competent." However, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). For certain chronic disorders, such as cardiovascular-renal disease (to include coronary artery disease and hypertension), service connection may be granted on a presumptive basis if the disease is manifested to a compensable degree within one year following service discharge. 38 U.S.C.A. §§ 1101, 1112 (West 2014); 38 C.F.R. §§ 3.307, 3.309 (2015). Under section 3.310 of VA regulations, service connection may be established on a secondary basis for a disability which is proximately due to, or aggravated by, service-connected disease or injury. Disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Where a service-connected disability aggravates a nonservice-connected condition, a Veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Allen, 7 Vet. App. at 448. Temporary or intermittent flare-ups of symptoms of a condition, alone, do not constitute sufficient evidence aggravation unless the underlying condition worsened. Cf. Davis v. Principi, 276 F. 3d 1341, 1346-47 (Fed. Cir. 2002); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). With regard to aggravation of nonservice-connected disabilities, for claims filed on or after October 10, 2006, any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. The baseline and current levels of severity will be determined under the VA Schedule for Rating Disabilities, and the extent of aggravation will be determined by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level. 38 C.F.R. § 3.310(b). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107(b). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. See Gilbert, 1 Vet. App. at 54. The Veteran seeks entitlement to service connection for a recurrent heart disorder. He asserts that his heart disorder is a direct result of medications prescribed, to include Vioxx, Bextra and Valcoxib, to treat his service-connected osteoporosis. The Veteran contends that he had multiple myocardial infarctions as a result of the use of these medications that precipitated the need for triple bypass/CABG surgery. He states that he does not claim any medication was the root cause of his existing coronary artery disease, but that the medications exacerbated/aggravated his existing coronary artery disease. See statements received July 2006, January 2008, February 2009 and April 2010. The Veteran submitted an April 2005 United States Food and Drug Administration (FDA) research paper in support of his service connection claim, which concluded that "the three approved COX-2 selective NSAIDs (i.e., celecoxib, rofecoxib, and valdecoxib) are associated with an increased risk of serious adverse [cardiovascular] events compared to placebo" and Bextra should be removed from the United States market. The Veteran's service treatment records are devoid of reference to complaint of, or treatment for, any cardiovascular/heart problems. At the time of a March 1983 discharge examination, clinical evaluation of the Veteran's heart and vascular system were normal. The Veteran underwent a VA heart examination in May 2007. He reported that he had his first heart attack in 2004 and underwent three vessel CABG surgery in 2004, with MRSA in the sternum during recovery. The Veteran indicated that he underwent reconstructive surgery of his sternum in 2004. He reported that he was a former smoker and that he had quit in 2001. Prior to this, he used to smoke one and one-half pack of cigarettes for 10 years. The Veteran also had a history of hyperlipidemia and was borderline diabetic. The Veteran reported that he was treated for osteoporosis with Bextra beginning in 2000 and took this medicine for two years. Following a detailed physical examination, the Veteran was diagnosed with CAD status post three vessel CABG in 2004. The examiner reported that the Veteran was a smoker and had a family history of CAD and hypertension, and that he was also male and had hyperlipidemia, which were all strong risk factors for CAD prior to his start on Bextra. The examiner further stated that Bextra is a good medication for treatment of his pain associated with osteoporosis and that there are risks and benefits involved when you take any medications. The examiner concluded by stating that Bextra does not by itself cause CAD; that in this Veteran's situation, the timing of his CAD and Bextra use are coincidental; that his greatest risk factors for CAD were smoking, family history, being male, hypertension and hyperlipidemia, not Bextra; and that it was the examiner's final opinion that Bextra is less likely the cause for his CAD. Since the May 2007 VA examiner did not comment on the FDA research paper and did not address whether or not the Veteran's CAD had increased in severity beyond its natural progression as the result of his service-connected osteoporosis and the medications prescribed for its treatment, including Bextra, the Board remanded the claim for another VA cardiovascular examination. The Veteran underwent a VA heart conditions Disability Benefits Questionnaire (DBQ) in September 2014, at which time he reported that he was on Valdecoxib in 2004 and that he is claiming that Bextra aggravated the CAD. The Veteran indicated that he knew that the Bextra is not the cause and that the CAD was due to years of "living too well". The Veteran reported that he started having chest pain and heart problems in 2004 and his blood pressure was going up. He came to VA in July 2004 and was given chemical stress test. He claims he was sent home though he was supposed to have been kept in hospital. He reportedly waited five days but had to come back because "I knew I was in trouble." He stated that at that time, he had a bad reaction to steroid treatment. During a second hospitalization, it was recognized that he had a heart problem. Catheterization found obstructions and he had CABG. Just prior to surgery while he was in the hospital, he developed an infection on the left hand (IV site). He knew that protocol was no surgery for seven days after infection but they did not wait, instead hanging antibiotics and going ahead with the surgery. The Veteran reported that the CABG was great and he felt they saved his life, but he developed MRSA in the chest. He reported he went back to VA and showed them the oozing, but VA was not sure what to do and he was sent back to his primary care physician, who swabbed it. Before he was notified of results he "fell out" and was delirious. The Veteran reported that he had to be re-opened and was left open for three weeks to get out all the necrotic tissue. He indicated that he was in a medically induced coma for at least a week; that bone and tissue were removed; and that he had muscle flap in this chest "to hold my heart in my chest." The Veteran reported that he could not throw things with his right arm due to this and that he still had problems with his heart. He reported needing to go to the hospital on at least two occasions, but both times the symptoms were pulmonary instead of related to the heart. It was noted the Veteran was on oxygen for COPD with emphysema, which he had had since he was 20 something. The Veteran also reported that he was on Valcoxib (Bextra), but stopped it just prior to the surgery, and that he was on antibiotics for MRSA at least a year after surgery. He stated that VA did not follow protocol for the MRSA and that they did not know what to do when he presented. The examiner provided a detailed review of pertinent post-service treatment records and also reported that service treatment records were silent for heart disease and that there is no indication of heart disease within two years of the Veteran's release from active duty service. The examiner also reviewed the FDA alert dated April 7, 2005. After that and a detailed physical examination, it was the examiner's opinion that the Veterans CAD status post CABG is not due to service and did not originate during active service. The rationale was that service treatment records and the medical record within two years of the Veteran's release from active duty are silent for coronary artery disease or other heart condition. The examiner also provided an opinion that the Veterans CAD status post CABG is not related to and/or increased in severity beyond its natural progression due to the Veteran's service connected osteoporosis, his other service connected disorders, and/or the medications prescribed for treatment of the service connected disorders, including Bextra. The rationale was that there was no causative relationship between the Veteran's service-connected conditions and medication treatment, to include Bextra, and the onset of coronary artery disease. The examiner further noted that the Veteran's coronary artery disease, as he himself admits, is due to lifestyle factors. Regarding the question of aggravation, the examiner reported that the Veteran's heart disease had been under control since the bypass surgery; that he had not had a recurrence of coronary occlusion; that cardiac catheterization in 2010 revealed patent grafts; that two hospitalizations in February 2007 and September 2012 found that the Veteran had not had a repeat myocardial infarction and that he did not have a cardiac cause for his chest pain; and that subsequent cardiac testing had not been found needed by his treatment providers. The examiner also noted that when Bextra was discontinued, it was stopped due to concerns about the Veteran's renal function, not out of concern for a cardiac complication, and further noted that Bextra was discontinued prior to the April 2005 FDA alert. The preponderance of the evidence is against a finding of service connection for a recurrent heart disorder, to include CAD and CABG residuals, on a direct basis. As noted above, service treatment records are devoid of reference to complaint of, or treatment for, any problems related to the Veteran's heart/cardiovascular system. In addition, the Veteran has not asserted, and there is no probative evidence establishing, that the Veteran's recurrent heart disorder, to include CAD and CABG residuals, had its onset during active duty service or that a recurrent heart disorder, to include CAD and CABG residuals, is related to such service. Rather, the September 2014 VA examiner provided an opinion that the Veteran's CAD status post CABG is not due to service and did not originate during active service, citing the absence of evidence of coronary artery disease or other heart condition in the service treatment records and the medical record within two years of the Veteran's release from active duty. This opinion is afforded high probative value. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (a factor for assessing the probative value of a medical opinion includes the thoroughness and detail of the opinion). The preponderance of the evidence is also against a finding of service connection for a recurrent heart disorder, to include CAD and CABG residuals, on a secondary basis. The May 2007 VA examiner provided an opinion that the Veteran's use of Bextra is less likely the cause for his CAD. In support of this opinion, the examiner indicated that Bextra does not by itself cause CAD; that in this Veteran's situation, the timing of his CAD and Bextra use are coincidental; and that the Veteran's greatest risk factors for CAD were smoking, family history, being male, hypertension and hyperlipidemia, not Bextra. After reviewing the April 7, 2005, FDA alert submitted by the Veteran and the Veteran's extensive treatment records, the September 2014 VA examiner provided an opinion that the Veteran's CAD status post CABG is not related to his service connected osteoporosis, his other service connected disorders, and/or the medications prescribed for treatment of the service connected disorders, including Bextra. This opinion was supported by a detailed rationale, which cited the absence of a causative relationship between the Veteran's service-connected conditions and medication treatment (to include Bextra) and the onset of coronary artery disease; and the fact that the Veteran's coronary artery disease was due to lifestyle factors. Regarding the question of aggravation, the examiner provided an opinion that the Veteran's CAD status post CABG did not increase in severity beyond its natural progression due to the Veteran's service connected osteoporosis, his other service connected disorders, and/or the medications prescribed for treatment of the service connected disorders, including Bextra. This opinion was also supported by a detailed rationale, which cited the fact that the Veteran's heart disease had been under control since the bypass surgery; that he had not had a recurrence of coronary occlusion; that cardiac catheterization in 2010 revealed patent grafts; that two hospitalizations in February 2007 and September 2012 found that the Veteran had not had a repeat myocardial infarction and that he did not have a cardiac cause for his chest pain; and that subsequent cardiac testing had not been found needed by his treatment providers. The examiner also noted that when Bextra was discontinued, it was stopped due to concerns about the Veteran's renal function, not out of concern for a cardiac complication, and further noted that Bextra was discontinued prior to the April 2005 FDA alert. The opinions provided by the May 2007 and September 2014 VA examiners, which stand uncontroverted in the record, are afforded high probative value. See Prejean, 13 Vet. App. at 448-9. The Board acknowledges the Veteran's assertions that his recurrent heart disorder, to include CAD and CABG residuals, is secondary to his use of medications prescribed to treat his service-connected osteoporosis. As a lay person without the appropriate medical training and expertise, however, he simply is not competent to provide a probative opinion that his current condition is secondary to a service-connected disability. See Bostain v. West, 11 Vet. App. 124, 127 (1998), citing Espiritu v. Derwinski, 2 Vet. App. 492 (1992); see also Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"). In the absence of any probative evidence that the Veteran's recurrent heart disorder, to include CAD and CABG residuals, is proximately due to or aggravated by his service-connected osteoporosis or the medications he took for the osteoporosis, service connection is not warranted on a secondary basis. 38 C.F.R. § 3.310. Lastly, the preponderance of the evidence is also against a finding of service connection for a recurrent heart disorder, to include CAD and CABG residuals, on a presumptive basis, as there is no evidence of cardiovascular-renal disease (to include coronary artery disease and hypertension), within one year of the Veteran's March 1983 discharge from active duty service. As the preponderance of the evidence is against the claim, the statutory provisions regarding resolution of reasonable doubt are not applicable. 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 54. 38 U.S.C.A. § 1151 The Veteran seeks entitlement to compensation pursuant to 38 U.S.C.A. § 1151 due to the development of the MRSA infection as a result of surgery performed for his heart condition. The Veteran asserts that he was admitted to the Gainesville VA Medical Center (VAMC) on August 23, 2004, and was scheduled for three vessel/CABG surgery on September 13, 2004, which had been delayed due to an infection at the IV site. On September 19, 2004, he was discharged with a temperature. On the morning of September 23, 2004, he noticed some drainage from the base of his suture site. He went back to the Gainesville emergency room and was routed to urgent care for blood work and where specimen cultures were ordered. The Veteran was seen for follow up the following day and was seen by a nurse practitioner, which he alleges was negligent. The Veteran also alleges that gross negligence and incompetence occurred on October 1, 2004, when he was allowed to leave the hospital. He returned to the emergency room on October 7, 2004, and does not remember anything after that until mid-November, when he was removed from the ventilator. The Veteran asserts that he developed MRSA as a result of the surgery and that there was incompetence and grossly negligent acts in failing to determine that he had gotten the infection. See statements received June 2006, July 2006, January 2008 and April 2010. Compensation shall be awarded for a qualifying additional disability or a qualifying death of a Veteran in the same manner as if such additional disability or death were service-connected. For purposes of this section, a disability or death is a qualifying additional disability or qualifying death if the disability or death was not the result of the Veteran's willful misconduct and the disability or death was caused by hospital care, medical or surgical treatment, or examination furnished the Veteran under any law administered by the Secretary, either by a Department employee or in a Department facility. In addition, the proximate cause of the disability or death must be either carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the Department in furnishing the hospital care, medical or surgical treatment, or examination; or an event not reasonably foreseeable. 38 U.S.C.A. § 1151. To determine whether a Veteran has an additional disability, VA compares the Veteran's condition immediately before the beginning of the hospital care, medical or surgical treatment, examination, training and rehabilitation services, or compensated work therapy program upon which the claim is based to the Veteran's condition after such care, treatment, examination, services, or program has stopped. VA considers each involved body part or system separately. See 38 C.F.R. § 3.361(b). To establish causation, the evidence must show that the hospital care, medical or surgical treatment, or examination resulted in the Veteran's additional disability or death. Merely showing that a Veteran received care, treatment, or examination and that the Veteran has an additional disability or died does not establish causation. See 38 C.F.R. § 3.361(c)(1). To establish that carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing hospital care, medical or surgical treatment, or examination proximately caused a Veteran's additional disability or death, it must be shown that the hospital care, medical or surgical treatment, or examination caused the Veteran's additional disability or death, and VA failed to exercise the degree of care that would be expected of a reasonable health care provider; or VA furnished the hospital care, medical or surgical treatment, or examination without the Veteran's or, in appropriate cases, the Veteran's representative's informed consent. Consent may be express (given orally or in writing) or implied under the circumstances specified in 38 C.F.R. § 17.32(b). 38 C.F.R. § 3.361(d)(1)(ii). Whether the proximate cause of a Veteran's additional disability or death was an event not reasonably foreseeable is to be determined based on what a reasonable health care provider would have foreseen. The event need not be completely unforeseeable or unimaginable but must be one that a reasonable health care provider would not have considered to be an ordinary risk of the treatment provided. In determining whether an event was reasonably foreseeable, VA will consider whether the risk of that event was the type of risk that a reasonable health care provider would have disclosed in connection with the informed consent procedures of 38 C.F.R. § 17.32. 38 C.F.R. § 3.361(d)(2). The Veteran was admitted on August 30, 2004, with complaint of left sided chest pain with nausea and shortness of breath. In pertinent part, left heart catheterization revealed obstructions of the circumflex, ramus intermedius and left atrial dimension and a CABG procedure and harvest of vein from bilateral legs was scheduled. The CABG was postponed due to cellulitis of the left hand at the previous IV site and was finally conducted on September 13, 2004. The informed consent documentation indicates that the nature and purpose of the operation or procedure, possible alternative methods of treatment, the risks involved, and the possibility of complications were fully explained to the Veteran and that he acknowledged that no guarantees had been made to him concerning the results of the operation or procedure. The Veteran was also counseled as to the nature of the proposed procedure, attendant risks involved, and expected results, and the Veteran indicated that he understood the proposed procedure, attendant risks involved, and expected results and requested the procedure be performed. The Veteran presented to the clinic on September 23, 2004, with chest pain, shortness of breath, and purulence from the incision site. The Veteran was started on Tequin with no improvement and the area was subsequently opened up and drained, but continued to worsen. The Veteran was admitted on October 7, 2004, with MRSA. The Veteran underwent debridement and irrigation on October 14, 2004, with necrotic bone seen. The Veteran underwent sternal debridement and pectus flap on October 28, 2004. He was started on Vancomycin. He was discharged on November 10, 2004, after a prolonged and complicated hospital course requiring mechanical ventilation. On his first post-operative clinic visit on November 19, 2004, the incision was noted to be healing very well and there were no signs or symptoms of infection or sternal instability. The Veteran was seen in the emergency room on December 17, 2004, with complaint of sudden increase in left chest pain and swelling. Examination revealed a large area of soft tissue swelling over the left lateral chest, mild tenderness, and some ecchymosis laterally. There was no erythema and the chest incision was noted to be clean, dry and intact and well-healed. The Veteran was admitted between September 20, 2005, and September 22, 2005, for shortness of breath. Discharge diagnoses included multifactorial shortness of breath; congestive heart failure in setting of nonadherence to Lasix regiment; untreated sleep apnea; and chronic obstructive pulmonary disease with need for oxygen. Secondary diagnoses included CABG with sternal osteomyelitis. The Veteran underwent a bilateral mammogram on February 17, 2006, due to left breast tenderness and swelling post CABG procedure. The impression was unremarkable bilateral mammogram demonstrating no evidence of mass or fluid collection. The Veteran was admitted from March 1, 2006, to March 2, 2006, due to concern of new MRSA infection since he stated his wound had begun to hurt and this was associated in the past with infection. The wound was carefully evaluated and no external signs of acute infection were found. CT was negative for abscess or fluid collection. ESR was only six, which was not consistent with acute osteomyelitis or infection. In one record, it was noted that due to the Veteran's history of recent hospitalization for sternal wound infection with MRSA, MRSA versus institution-acquired pneumonia was presumed. It was also noted that sputum culture did not show MRSA or any organisms of concern. The discharge diagnosis was community acquired pneumonia. The Veteran was admitted between April 13, 2006, and April 18, 2006, due to chest pain with history of MRSA mediastinitis. He was admitted for PICC line placement to begin long course of IV antibiotics due to CT scan and bone scan showing possible recurrence of mediastinitis. The discharge diagnosis was MRSA mediastinitis. He was discharged home with an IV antibiotic course with Vancomycin for approximately six weeks. The Veteran was admitted between September 24, 2006, and September 27, 2006, with fever, chills and new right lower lobe pneumonia. It was noted that had chronic mediastinitis since CABG and had been on antibiotics. The impression was community acquired pneumonia in the background of MRSA mediastinitis. During this admission, a scar at the mid-sternum from CABG was noted to be warm, dry, and intact without redness, swelling or ulcerations. The discharge diagnosis was right lower lobe pneumonia. The Veteran was admitted between February 1, 2007, and February 7, 2007, due to chest pain. It was noted that the Veteran had a history of MRSA sternotomy infection and complaint of discharge at the scar site. At the time of admission, the Veteran had gold crusty lesions but no discharge. He was cultured from nares for MRSA colonization and was negative. No further wound treatment was needed as the CABG site was clean, dry and intact and well-healed. The Veteran was referred for admission on September 6, 2007, due to complaint of productive cough, sub fever, and chills. He reported he needed to be given Vancomycin for MRSA because it had nearly killed him many times and he was certain it would take his life. It was noted that the Veteran had a history of recurrent right lower lobe pneumonia and that he was on lifelong Bactrim suppression for MRSA osteomyelitis. In the assessment portion of the report, it was noted there was no indication for MRSA coverage, which was explained to the Veteran though he did not agree. He also did not want to stay in the hospital for just regular antibiotics. VA treatment records dated in May 2009 indicate that the Veteran self-discontinued the Bactrim in January 2009 due to symptoms of fatigue and nausea. Since discontinuing then suppression antibiotics, he had not noticed any discharge from the sternal wound or worsening pain at the incision site or sternum. There was objective evidence of a keloid scar of the midline sternotomy incision with no active discharge and sensitivity to palpation that was unchanged for several years. Per the Veteran, he occasionally saw some clear drainage from the lower aspect of the incision site whether he is on medication or not. There was no current active drainage, even on the pressure site. The impression was chronic MRSA sternal osteomyelitis since 2004 status post treatment with IV antibiotics followed by Bactrim most of the time (with brief period of Doxycycline suppression in 2006) until three months ago for total of four to five years. It was again noted that there was no active discharge and that the wound was well healed with keloid scar. The Veteran wanted to be off antibiotic suppression and watch it and the physician agreed. The Veteran underwent a VA infectious, immune, and nutritional disabilities examination in May 2007, at which time he reported that he contracted MRSA while he had surgery for CAD with bypass surgery. He was hospitalized for this infection and this surgery, and had to have rehospitalization and long term antibiotics for the MRSA. He now had to take sulfamethoxazole and trimethoprim (SMX-TMP) for this infection daily. Physical examination revealed a midline scar that was well healed. The diagnosis was MRSA infection in his wound. The examiner noted that this was a complication from his heart surgery and he now had to take SMX-TMP daily as prophylaxis and treatment for this infection. It was the examiner's opinion that it is more likely that he had this infection as a result of the heart surgery. In a June 2007 compensation and pension note authored by the May 2007 examiner, it was determined that the Veteran's MRSA infection that resulted from the heart surgery was most likely due to an event to reasonably foreseeable by the medical staff. It was specifically noted that this type of infection is not an uncommon complication from the surgery. It appears the Board may have overlooked the June 2007 addendum from the May 2007 VA examiner, since it remanded the claim for another examination, noting that the May 2007 VA examiner did not address whether the MRSA infection was either a reasonably foreseeable risk of the surgical procedure or due improper treatment by VA medical personnel. The Veteran underwent a VA infectious disease DBQ in September 2014, at which time he was diagnosed with MRSA sternal wound infection, resolved with residual scar. The examiner noted that there was ample evidence of the chest wound post CABG but determined there was no current MRSA infection. The examiner also completed a VA scars/disfigurement DBQ. The diagnosis was chest scar due to MRSA infection status post CABG. The examiner indicated that the scar was mid chest, which was the usual location for a CABG scar, and that there was the typical "railroad" appearance of a wound that healed by secondary intention. In regards to whether the cause of the MRSA was due to carelessness etc., the examiner did not render an opinion due to conflict of interest since the claim was against the medical center where the examiner was employed. Another opinion was obtained in November 2014. The examiner reviewed the Veteran's claims file, VA medical records, and VBMS electronic record and cut and pasted the September 2014 DBQ reports, the June 2007 VA opinion, and other pertinent VA treatment records, to include records associated with the CABG surgery and subsequent treatment following the surgery, into the opinion. It was the November 2014 VA examiner's opinion that the Veteran's post-operative infected mediansternotomy incision with MRSA, diagnosed as sternal osteomyelitis with MRSA, status post sternal debridement and pectoralis muscle flap, status post Vancomycin IV 6 weeks and Minocycline suppression October 2004 to October 2006 follow up with recurrence of infection and retreatment with Vancomycin IV for four to six weeks between April 13, 2006, and May 18, 2006, and placed on Bactrim DS long term suppression (with brief period of Doxycycline suppression in 2006) until early 2009, for total four to five years, currently off antibiotic suppression with MRSA sternal wound infection, resolved, with residual mediansternotomy scar, was at least as likely as not (50 percent probability or greater) a reasonably foreseeable risk of the surgical procedure, and not due to improper treatment by VA medical personnel, to include carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the VA. The rationale was that the Veteran was admitted for myocardial infarction on August 23, 2004, and underwent CABG surgery on September 13, 2004. His surgery was delayed to treat an exacerbation of the Veteran's COPD and cellulitis of the left hand. After being cleared for surgery by anesthesiology, the Veteran had an appropriate pre-surgical preparation ordered to include: "*CHLORHEXIDINE GLUCONATE LIQUID,TOP 4% A LIBERAL AMOUNT TOP QD (TREATMENT) Please apply HIBICLENS scrub to CHEST and BOTH LEGS in evening 9/12, and at 05:00 9/13 in preparation for CABG on 9/13. PLEASE FLAG FOR RN STAFF and CEFAZOLIN INJ 1GM/VIAL, 2 GM IVPB ON CALL." The examiner reported that the Veteran's post-operative course in the hospital was uncomplicated and he was discharged on September 19, 2004. The Veteran called to come in after he "bent over and started draining from surgical incision" the night of September 22, 2004, and was seen by primary care on September 23, 2004. He was initially diagnosed with wound infection and treated with Tequin 400mg QD. The initial post-operative evaluation by surgery on September 24, 2004, was that antibiotic treatment with Tequin would be continued, with wound care instruction. At post-operative evaluation on October 1, 2004, the Veteran presented with increased erythema at inferior mediansternotom (MS) incision site and purulent drainage, and 5cm long x 1.5cm deep abscess was opened and Tequin course was extended another four days. On October 7, 2004, the Veteran presented to the emergency room with sternal wound infection and was admitted with MRSA diagnosed sensitive to Vancomycin. The Veteran underwent mediastinal wound exploration and debridement by Cardiothoracic Surgery on October 14, 2004, and a subsequent sternal debridement with pectus flap by Plastic Surgery on October 28, 2004, as well as infectious disease consultation, with discharge home on November 10, 2004, on suppressive antibiotic treatment. He underwent an infectious disease consultation on December 2, 2004, with plan to complete fifth week of IV Vancomycin, and he was noted to be doing well with well-healed wound. The decision was made to pull PICC line due to irritation at PICC insertion site; the Veteran was continue on linezolid and transition after one week to chronic suppressive therapy on Minocycline for 6 months to a year. Complication of left chest wall hematoma was drained on December 17, 2004. In January 2006, the Veteran had a recurrent wound infection that responded to Vancomycin with Infectious Disease Consultation on May 18, 2006, with assessment and plan of recurrent sternal wound infection - responded well to a 6-week course of Vancomycin, stop Vancomycin. Will need a very long time suppressive therapy with Bactrim (may be lifelong). The examiner noted that the Veteran continued on Bactrim until early 2009 and that an Infectious Disease Consultation on May 4, 2009, noted he had a keloid scar (mediansternotomy) no drains, erythema or edema with assessment and plan of on chronic suppression with Bactrim since 2004 until January 2009. It was noted at that time that the Veteran had stopped his Bactrim due to feeling nauseous while on Bactrim for three months; that there was no change (wound) since stopping Bactrim; and that the Veteran would stop Bactrim and monitor the wound at home. The November 2014 VA examiner also reported that review of the literature shows clearly that wound infection in the incision is a common postoperative complication in coronary artery bypass graft surgery. The examiner cited the reference article Association of pre and intraoperative variables with postoperative complications in coronary artery bypass graft surgery in which the authors concluded that "an increase in complex sternal site infection rates can be partially explained by the increasing proportion of patients with more severe underlying disease." The examiner also noted that an association between sicker patients and increased infection rate was also found in the reference article, Increase in the rate of sternal surgical site infection after coronary artery bypass graft: a marker of higher severity of illness, in which the authors concluded that "an increase in infection in the CABG population not associated with an outbreak may be a reflection of a change in the severity of illness." The November 2014 VA examiner again provided an opinion that the Veteran's post-operative infected mediansternotomy incision with MRSA, diagnosed as sternal osteomyelitis with MRSA, status post sternal debridement and pectoralis muscle flap, status post Vancomycin IV 6 weeks and Minocycline suppression October 2004 to October 2006 follow up with recurrence of infection and retreatment with Vancomycin IV for four to six weeks between April 13, 2006, and May 18, 2006, and placed on Bactrim DS long term suppression (with brief period of Doxycycline suppression in 2006) until early 2009, for total four to five years, of suppression, was a reasonably foreseeable risk of the surgical procedure, and not due to improper treatment by VA medical personnel. After review of the evidence, the Board finds that service connection is not warranted for recurrent MRSA infection residuals under 38 U.S.C.A. § 1151. Initially, the Board notes that the evidence suggests that an additional disability may have onset as a result of the CABG surgery performed by VA, namely the development of recurrent MRSA infections at the mediansternotomy incision site and residual mediansternotomy scar. The Board acknowledges that the Veteran was admitted on October 7, 2004, with MRSA after complaining of purulent discharge from the incision site in September 2004, which required debridement, irrigation, and pectus flap with prolonged medication; and that he was seen on several occasions with complaints of suspected MRSA, which culminated in an April 2006 admission for MRSA mediastinitis. Following the April 2006 VA admission, however, there was no recurrence of MRSA, even when the Veteran self-discontinued the medication that he had been prescribed for life, and there were no scar abnormalities noted (reported to be warm, dry and intact, without redness, swelling or ulcerations in September 2006; clean, dry and intact, and well-healed in February 2007; without active discharge and well-healed keloid scar in May 2009; well-healed during the May 2007 VA examination; and healed by secondary intention during the September 2014 VA examination). In addition, the evidence does not suggest that either the recurrent MRSA infections or the residual mediansternotomy scar were the result of VA carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault. Rather, the evidence establishes that both were reasonably foreseeable events. More specifically, while acknowledging that the infections were the result of the CABG surgery, the May 2007 VA examiner provided an addendum opinion in June 2007 that this was a reasonably foreseeable event as this type of infection is not an uncommon complication from surgery. The November 2014 VA examiner provided an opinion that they were reasonably foreseeable risks of the surgical procedure and not due to improper treatment by VA medical personnel, to include carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA, citing medical literature that clearly shows wound infection in the incision is a common postoperative complication in CABG surgery. Both opinions are afforded high probative value. See Prejean, 13 Vet. App. at 448-9. The Board acknowledges the Veteran's assertions that he developed MRSA as a result of his CABG surgery and that there was incompetence and grossly negligent acts in failing to determine that he had gotten the infection. The Board also again acknowledges that the Veteran was seen on several occasions following the CABG surgery with actual and suspected MRSA infection, to include an April 2006 admission for MRSA mediastinitis. As a lay person without the appropriate medical training and expertise, however, he simply is not competent to provide a probative opinion that any additional disability that onset as a result of the CABG surgery performed by VA was due to carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the Department in furnishing the surgical treatment, or that any additional disability was due to an event not reasonably foreseeable. See Bostain v. West, 11 Vet. App. 124, 127 (1998), citing Espiritu v. Derwinski, 2 Vet. App. 492 (1992); see also Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"). The probative opinions provided by the May 2007 and November 2014 VA examiners stand uncontroverted in the record. As there is no competent and probative medical evidence to the contrary (that the development of the additional disabilities of recurrent MRSA infections at the mediansternotomy incision site and residual mediansternotomy scar was not reasonably foreseeable), the Board finds that the Veteran's recurrent MRSA infection residuals was an event reasonably foreseeable, and thus, that service connection is not warranted under 38 U.S.C.A. § 1151. ORDER Service connection for a recurrent heart disorder, to include CAD and CABG residuals, is denied. Entitlement to compensation under the provisions of 38 U.S.C.A. § 1151 for recurrent MRSA infection residuals is denied. ____________________________________________ R. FEINBERG Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs