Citation Nr: 19190837 Decision Date: 12/03/19 Archive Date: 12/03/19 DOCKET NO. 16-38 276 DATE: December 3, 2019 REMANDED Entitlement to service connection for a valvular heart disease, to include residuals of an aortic valve replacement, is remanded. Entitlement to service connection for migraine headaches is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from July 1975 to July 1995. This appeal comes to the Board of Veterans’ Appeals (Board) from a rating decision, dated January 2016, issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma (hereinafter Agency of Original Jurisdiction (AOJ)). In its decision, the RO denied service connection for valvular heart disease, including mitral and aortic valve replacement, and migraine headaches since these disabilities neither occurred in nor were caused by service. The Veteran timely appealed. A Board video hearing was held before the undersigned Veterans Law Judge in September 2019. The hearing transcript has been associated with the Veteran’s file.   1. Entitlement to service connection for a valvular heart disease, to include residuals of an aortic valve replacement, is remanded. Although the Board regrets the additional delay, the Veteran’s remaining claim must be remanded before the Board is able to make a determination on the merits. Specifically, the Board finds that additional supporting evidence is required in developing the Veteran’s claim. The Veteran contends that his heart disability began while in service. The Veteran reported that this condition began with an occupational physical that noted when he noticed an irregular heart beat/rate. The condition has only become worse since that physical. The Veteran reported constant clicking of mechanical heart valves incision hyperextended requiring Cortizone injections. The Veteran was afforded a VA examination for heart conditions (including ischemic & non-ischemic heart disease, arrhythmias, valvular disease and cardia surgery) in July 2015. The VA examination shows the Veteran was diagnosed with valvular heart disease in July 2013. The examination noted that the Veteran did not experience angina, shortness of breath, fatigue, dizziness or syncope attacks. The Veteran’s heart conditions did not qualify within the generally accepted medical definition of ischemic heart disease (IHD). He reported taking Lisinopril, Allopurinol, Zocor, Carvedilol, Warfarin, Zolmitriptan, Valtrex, and Zantac to control his heart condition. He did not have myocardial infarction. Although the Veteran had congestive heart failure in the past, he did not have chronic congestive heart failure or any episodes of acute congestive heart failure in the year prior to the VA examination. He did not have cardiac arrhythmia. The Veteran had an aortic heart valve condition in the past as he had a mitral and aortic valve replacement in July 2013. He had not had any infectious cardiac conditions, including active valvular infection (including rheumatic heart disease), endocarditis, pericarditis or syphilitic heart disease. There was evidence of cardia hypertrophy documented on an echocardiogram in July 2015. A June 2015 EKG showed normal results. A June 2015 chest X-ray showed abnormal results described as old granulomatous disease, postoperative findings at the sternum/cardia region, minimal bibasilar atelectasis and scarring, small hiatal hernia. An August 2015 MET showed dyspnea and fatigue. The Veteran’s heart condition did not impact his ability to work. The VA examiner wrote that congestive heart failure was not found during this examination. Therefore, the examiner concluded that the Veteran had an acute episode of congestive heart failure in the past, but this was not chronic. Accordingly, there was no diagnosis of congestive heart failure during the July 2015 VA examination. In a March 2016 follow-up visit, a physician provided that the Veteran had severe aortic stenosis and presented with heart failure. Mitral regurgitation was severe. He had a mitral valve replacement and an aortic valve replacement in July 2013. He presented on July 2 with acute decompensation and volume overload. A heart catheterization was done, and no significant coronary disease was seen. He had done well since then. There was no mention of valvular disease on his service discharge examination; however, according to the physician, he most likely did have some aortic stenosis, either acquired or congenital, and it was not picked up during his initial service physical, examinations during his service, or his discharge physical. A December 1995 treatment record provided an examination of the heart which revealed a grade III rough systolic murmur in the pulmonic area. However, while the Veteran had a heart examination on his heart in July 2015, the Board finds that a remand is required in order to determine if the Veteran’s heart murmurs in 1995 lead to the Veteran’s current valvular heart disease, to include residuals of an aortic valve replacement. The examiner must determine if any current heart disability is etiologically related to the heart murmur that the Veteran experienced within one year of service is sufficient to establish a cardiac disability. Therefore, the Veteran’s claim for a valvular heart disease, to include residuals of an aortic valve replacement is remanded for a new VA examination. As the Veteran’s claim is being remanded, the Board requests that the AOJ contact the Veteran to ensure all available medical records have been obtained and associated with the claims file. The VA’s duty to assist includes obtaining records of relevant VA medical treatment. 38 U.S.C. § 5103A(c)(2); 38 C.F.R. § 3.159(c)(2), (c)(3). See also Bell v. Derwinski, 2 Vet. App. 611 (1992) (The VA is charged with constructive, if not actual, knowledge of evidence generated by the VA). Therefore, the AOJ should obtain and associate with the claims file any outstanding VA medical records, assuming they are adequately identified by the Veteran after any necessary clarification. 2. Entitlement to service connection for migraine headaches is remanded. Although the Board regrets the additional delay, the Veteran’s remaining claim must be remanded before the Board is able to make a determination on the merits. Specifically, the Board finds that additional supporting evidence is required in developing the Veteran’s claim. The Veteran reported that he went to the medical sick hall for migraines in 1976 while in service. See Hearing Transcript dated September 2019. At that time, he was given a prescription for Tylenol for treatment. After that, he took care of the migraines on his own as far as medication and over-the-counter stuff. Following service, he was given Flexeril, a muscle relaxer, and two injections of Cortisone in the back of his neck, head, or nerve for his migraines. This worked for about a month until they started coming back again. The Veteran testified that he had surgery on a pinched nerve in the back of his neck, but this did not prevent his migraines from occurring. There was some indication in the file about a traumatic brain injury. The Veteran stated that he did not want to make a secondary service connection claim. He noted that the onset of his migraine type headaches began about one to two years after his 1978 fall but does not attribute his headaches to his fall in 1978. The Veteran was afforded a VA examination in August 2015 for his headaches. The VA examiner wrote that the Veteran began experiencing migraine headaches while in service in 1976. He went to sick call to receive treatment for these headaches. The Veteran’s service treatment records (STRs) noted that he had frequent severe headaches that began in 1973 and last occurred in 1975 when the Veteran quit smoking. The VA examiner opined that it was less likely than not that the Veteran’s migraine headaches were related to a specific exposure event experienced by the Veteran during his service in Southwest Asia. The VA examiner provided that the research published in peer-reviewed medical journals has not established a causal relationship between this disease and exposure events experienced by service members in Southwest Asia. For these reasons, the VA examiner provided that the Veteran’s migraine headaches were less likely than not incurred in or caused by the claimed in-service injury. Private treatment records from 1995 to the present are indicative of migraine headaches that occur almost daily. Recurrent headaches have been noted in numerous post-service medical records as reported by the Veteran. However, while the Veteran underwent a VA examination in August 2015 for his headaches, the VA examiner did not address the relationship between the Veteran’s current headaches and the headaches that he experienced while in service. Therefore, the Veteran’s claim for migraines is remanded for a new VA examination. As the Veteran’s claim is being remanded, the Board requests that the AOJ contact the Veteran to ensure all available medical records have been obtained and associated with the claims file. The VA’s duty to assist includes obtaining records of relevant VA medical treatment. 38 U.S.C. § 5103A(c)(2); 38 C.F.R. § 3.159(c)(2), (c)(3). See also Bell v. Derwinski, 2 Vet. App. 611 (1992) (The VA is charged with constructive, if not actual, knowledge of evidence generated by the VA). Therefore, the AOJ should obtain and associate with the claims file any outstanding VA medical records, assuming they are adequately identified by the Veteran after any necessary clarification. Accordingly, the matters are REMANDED for the following action: 1. The AOJ should contact the Veteran, and, with his assistance, identify any additional outstanding records of pertinent medical treatment for any heart disability and migraine headaches. In obtaining these records, the AOJ is instructed to follow the procedures for obtaining the records set forth by 38 C.F.R. § 3.159(c). If the AOJ’s attempts to obtain any outstanding records results in a finding that such records are unavailable, the Veteran should be notified in accordance with 38 C.F.R. § 3.159(e). 2. After any additional records are associated with the claims file, the AOJ should schedule the Veteran for a VA medical examination with an appropriate qualified physician. All necessary diagnostic testing and evaluation should be performed, and all findings set forth in detail. Based upon a review of the entirety of the claims file, the history presented by the Veteran, and the examination results, the examiner is requested to provide an opinion as to the following questions. (a.) Please identify any heart disability, to include residuals of an aortic valve replacement, that is currently manifested. (b.) For any heart disability, to include residuals of an aortic valve replacement, identified, is it at least as likely as not (i.e. probability of 50 percent or greater) that the disability was incurred during the Veteran’s active military service or within one year of discharge from service, to include the heart murmur that he experienced while in service. (c.) Please identify any migraine headaches that are currently manifested. (d.) For any migraine headaches identified, is it at least as likely as not (i.e. probability of 50 percent or greater) that the disability was incurred during the Veteran’s active military service, to include the migraine headaches that he was treated for while in service. Explanations for all opinions must be provided. In providing the requested rationale, the examiner is asked to cite to the pertinent evidence of record, including clinical records and the Veteran’s statements regarding the onset of his symptoms. DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Bristor The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.