Citation Nr: 18154529 Decision Date: 11/30/18 Archive Date: 11/30/18 DOCKET NO. 14-44 261 DATE: November 30, 2018 REMANDED The appeal as to the claim of entitlement to service connection for a heart disorder, to include as secondary to the service-connected chronic obstructive pulmonary disease (COPD), is remanded. The appeal as to the claim of entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities is remanded. REASONS FOR REMAND The Veteran had active service in the United States Navy from December 1969 to September 1979. His service was under honorable conditions. These matters are on appeal from February and April 2011 rating decisions. Although the December 2014 Statement of the Case addressed the Veteran’s disagreement with the denial of entitlement to service-connection for a heart disorder, denial of an increased rating in excess of 30 percent for service-connected depression, and denial of a TDIU, the Veteran specifically limited his substantive appeal to the issues of service connection and TDIU addressed herein. 1. Entitlement to service connection for a heart disorder, to include as secondary to the service-connected COPD. The Veteran contends that his current heart disorders are due to active service. In the alternative, he asserts that the disorders are secondary to his service-connected COPD. The Veteran does not contend, nor does the evidence demonstrate, service in the waters of or the Republic of Vietnam during the Vietnam Era. Service treatment records are negative for complaints of, treatment for, or a diagnosis of a heart disorder. Post-service treatment records include a July 2007 VA record that indicates an abnormal heart with a heart murmur and dyspnea on exertion; calcific aortic stenosis was noted. An August 2007 VA record demonstrates the Veteran underwent a heart valve replacement due to severe aortic stenosis; coronary artery disease (CAD) is noted. A November 2007 VA examination report notes diagnoses of status post heart valve replacement, heart murmur, and unstable angina; x-ray shows cardiac enlargement. A December 2009 VA record notes diagnosed of a heart murmur, hypertensive heart disease, angina, and status post heart valve replacement. A September 2010 VA examination report notes diagnoses of CAD and aortic valve prosthesis, status post aortic stenosis. A March 2011 VA opinion notes that the Veteran’s current aortic valve prosthesis, status post aortic stenosis, was not related to or aggravated by the service-connected COPD. In providing this opinion, the examiner noted that the Veteran had a bicuspid aortic valve (a congenital condition) and the most common reason for the development of aortic stenosis. The examiner further noted that aortic stenosis is due to an age-related breakdown of the valve leaflets leading to calcification and subsequent stenosis. She indicated that the calcification is caused by the collagen breakdown in the valve leaflets and subsequent calcium deposition, noting that it was not related to a lifestyle choice, and not the same as CAD. The examiner concluded that there was no medical literature to suggest any correlation between the Veteran’s congenital condition and his COPD. The report of an August 2011 VA examination for COPD includes a chest x-ray of the heart. The examiner indicated that the Veteran’s heart was normal. A VA chest x-ray dated 8/15 demonstrates a normal heart size with prior surgical intervention. A September 2016 VA cardiology record notes the Veteran’s shortness of breath persisted; the examiner found no acute signs or symptoms. A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a) (2018). This includes any increase in severity of a nonservice-connected disease that is proximately due to or the result of a service-connected disability as set forth in 38 C.F.R. § 3.310(b). See also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). A claimant is also entitled to service connection on a secondary basis when it is shown that a service-connected disability aggravates a nonservice-connected disability. 38 C.F.R. § 3.310; Allen, 7 Vet. App. at 439. To date, the medical evidence of record in inadequate to adjudicate the claim. In this regard, clarification is necessary to determine if the Veteran presented with CAD during the pendency of the appeal. In this regard, VA records dated after the Veteran’s August 2007 heart surgery note a heart murmur, unstable angina, hypertensive heart disease, an enlarged heart, and CAD; however, the March 2011 VA opinion indicates that the Veteran’s aortic stenosis is a congenital defect, and not the same as CAD. In addition, while the March 2011 VA examiner opined as to the etiology of the current aortic valve prosthesis, status post aortic stenosis, and attempts to differentiate such disorder from CAD, she did not provide etiology opinions for the Veteran’s additional current heart disorders noted during the appeal period. Accordingly, another medical examination and opinion are necessary to make a determination in this case. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). 2. Entitlement to a TDIU. As the issue of an evaluation and proposed reduction for the service-connected COPD is currently being developed by the AOJ, and the issue of service connection for a heart disorder are directly applicable to the question of employability, the issue of TDIU is also remanded as inextricably intertwined. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two or more issues are inextricably intertwined if one claim could have significant impact on the other). Further, development to obtain any outstanding medical records pertinent to the Veteran’s claim should be completed. The matters are REMANDED for the following actions: 1. Undertake appropriate development to obtain any outstanding records pertinent to the Veteran's claims. If any requested records are unavailable, or the search for such records otherwise yields negative results, that fact should clearly be documented in the record and the Veteran so notified in accordance with 38 C.F.R. § 3.159(e). All steps taken to attempt to obtain the above records should clearly be documented in the record. 2. Schedule the Veteran for a VA examination before an appropriate physician to determine the etiology of any heart disorder present during the period on appeal, to include CAD, hypertensive heart disease, aortic valve prosthesis, status post aortic stenosis, a heart murmur, and an enlarged heart. The examiner must review the record, to include service treatment records, VA treatment records, VA examinations, and the Veteran’s statements. The examiner must also consider the Veteran's documented medical history, assertions, and reported symptoms. All indicated studies should be completed, and all clinical findings reported in detail. The physician must provide an opinion as to whether it is at least as likely as not (i.e., at least 50 percent probable) that any current heart disorder, to include CAD, hypertensive heart disease, aortic valve prosthesis, status post aortic stenosis, a heart murmur, and an enlarged heart, manifested during, or within one year, or as a result of, active military service. If not, the physician should state a medical opinion as to whether it is at least as likely as not (i.e., at least 50 percent probable) that the heart disorder(s) were caused or permanently worsened by the service-connected COPD. If the physician believes that a heart disorder was permanently worsened by the service-connected COPD, the physician should attempt to identify the baseline level of disability that existed prior to the onset of aggravation and the extent of disability that is attributable to aggravation. In providing the opinions, the examiner must comment on the post-service VA outpatient treatment records dated in 2007 and 2009, to include the August 2007 surgical report that indicates the Veteran underwent a heart valve replacement due to severe aortic stenosis and noted a diagnosis of CAD, the November 2007 VA examination report that notes diagnoses of status post heart valve replacement, heart murmur, unstable angina, and cardiac enlargement, the December 2009 VA outpatient record that includes a diagnosis of hypertensive heart disease, the September 2010 VA examination report that indicates diagnoses of CAD and aortic valve prosthesis, status post aortic stenosis, and the March 2011 VA opinion that notes that the Veteran’s current aortic valve prosthesis, status post aortic stenosis was not caused or aggravated by his service-connected COPD, and finds that his aortic stenosis is not the same as CAD. For purposes of the opinions, the examiner should assume that the Veteran is a credible historian. A complete rationale for all opinions offered must be provided. If the examiner is unable to provide any required opinion, the examiner should fully explain why this is the case. Likewise, if the examiner cannot provide an opinion without resorting to mere speculation, the examiner shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 3. The AOJ should ensure that the Veteran is provided with adequate notice of the date and place of all scheduled examinations. A copy of all notifications, including the address where the notice was sent, must be associated with the record if the Veteran fails to report for any examination. The Veteran is to be advised that failure to report for a scheduled VA examination without good cause may have adverse effects on his claim. 4. Then, the AOJ should readjudicate the issues on appeal. If the benefits sought on appeal are not granted to the Veteran’s satisfaction, he and his representative should be provided a supplemental statement of the case and an appropriate period for response before the case is returned to the Board for further appellate action. B. MULLINS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Sara Schinnerer, Counsel