Citation Nr: 20025317 Decision Date: 04/14/20 Archive Date: 04/14/20 DOCKET NO. 18-40 488 DATE: April 14, 2020 REMANDED Entitlement to service connection for valvular heart disease, status post aortic valve replacement is remanded. REASONS FOR REMAND The Veteran served honorably in the United States Army from August 1994 to August 1998 and from September 2007 to December 2008. For his meritorious service, the Veteran was awarded (among other decorations) the Army Achievement Medal. This matter comes before the Board of Veteran’s Appeals (Board) on appeal from a May 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). On his May 2015 Notice of Disagreement (NOD), the Veteran appealed the claim seeking service connection for his heart condition and seeking an increased evaluation for gout. On his August 2018 substantive appeal, the Veteran noted he was only appealing the claim seeing service connection for valvular heart disease; therefore, the claim for service connection for his heart condition is the only claim currently before the Board. 1. Entitlement to service connection for valvular heart disease, status post aortic valve replacement is remanded. The Veteran contends he is entitled to service connection for his valvular heart disease, status post aortic valve replacement (heart condition). The Veteran contends his aortic aneurysm should be considered and evaluated as part of the claim for service connection. He reports the aneurysm was caused by physical stress. He also contends he had migraines in-service and was being treated for the condition when the aneurysm was found. The Veteran reports the aneurysm was noted on his final physical in 1998. In support of his claim, the Veteran submitted a private Disability Benefits Questionnaire (DBQ) in May 2013. The private opinion provided the Veteran’s history of an aortic aneurysm and valve replacement in 2003 and noted the Veteran is on continuous medication for the control of his heart condition. The private opinion notes the etiology of the heart condition is unknown and that there is evidence of cardiac hypertrophy. Though this opinion is not adequate for the Board to grant a service connection, as there is no link to service or discussion of whether the condition was permanently worsened or aggravated, it certainly triggers the need for a VA examination. The Veteran’s July 1998 Report of Medical History from his service treatment records reflects the Veteran’s report of headaches, pain or pressure in his chest, and palpitation or pounding heart. His VA treatment records reflect a complex medical history. In his VA treatment records from 2013, his VA doctor noted the Veteran was unsure of the underlying etiology of his aortic valve or aneurysm, which the VA doctor noted was interesting, given its occurrence at his young age. The RO denied the Veteran’s claim for service connection on the basis that heart condition was diagnosed in 2003, which was not during active duty service. The Veteran re-entered active duty service in September 2007 with a physical profile. The RO stated there was no evidence to show the condition was permanently worsened or aggravated due to active duty service. The Veteran never underwent a VA examination for his heart condition. Here, the Veteran has a current disability and his service treatment records establishes an in-service reporting of cardiac concerns during active duty. The Veteran’s contentions, his complex medical history, and a VA examination will assist in determining if service connection elements are met. It is also important to consider the Veteran had a physical profile added to his record, as he was not able to be deployed to an environment that would prevent regular lab monitoring of anticoagulant status, which should be evaluated in evaluating the Veteran’s claim. Therefore, a remand is required to obtain a VA examination and opinion for service connection for the claimed disability. The Board notes the Veteran’s service treatment records from his first period of active duty service are not on file, therefore, it is necessary to obtain those records. The matter is REMANDED for the following actions: 1. Obtain the Veteran’s complete service treatment records and associate them with the Veteran’s file. 2. Schedule the Veteran for an appropriate VA examination to evaluate Veteran’s heart condition. After examining the Veteran, the examiner is to state whether it is at least as likely as not that the Veteran’s heart condition was incurred in, aggravated by, or is otherwise related to his periods of active service. In answering this question, the examiner must address and discuss the Veteran’s 1998 report of medical history noting cardiac concerns and whether that information is related to his for valvular heart disease, status post aortic valve replacement, and aortic aneurysm. The examiner must also state whether the Veteran’s heart condition was worsened or aggravated during his second period of active service. A complete rationale for all requested opinions must be provided. Evan M. Deichert Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Mouzakis, Associate Counsel 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.