Citation Nr: 20060720 Decision Date: 09/15/20 Archive Date: 09/15/20 DOCKET NO. 15-32 383 DATE: September 15, 2020 REMANDED Entitlement to service connection for subvalvular aortic stenosis is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty from September 1984 to April 1994, with additional unverified active service. This matter is before the Board of Veterans’ Appeals (Board) on appeal of a July 2011 Department of Veterans Affairs (VA) rating decision. In February 2017, a Travel board hearing was held before the undersigned; a transcript is in the record. On the Veteran’s July 1984 service entrance examination, a [non-disqualifying] heart murmur was noted; an echocardiogram was normal. This claim was previously denied on the basis that the Veteran’s cardiac disability pre-existed service and was not aggravated therein. A heart murmur, of itself, is a symptom and not a disability entity, and the Veteran is entitled to the presumption of soundness on entry in service with respect to a heart disability. That presumption may be rebutted only by clear and unmistakable evidence. And if the presumption of soundness on entry in service is rebutted by clear and unmistakable evidence, the Veteran is entitled to a further (rebuttable only by clear and unmistakable evidence) presumption that the pre-existing disability was aggravated by service, i.e., that there was no increase in disability during service or that any increase was due to the natural progression. See Wagner v. Principi, 370 F.3d 1089, 1096-97 (Fed. Cir. 2004). The Veteran reported her heart disability manifested in service (she would experience shortness of breath and fatigue that progressed to chest pains) and worsened during her time in the Reserves. She reported she continued to experience chest pains and shortness of breath after exercising for years while in the Reserves. An October 1986 service treatment record (STR) notes complaints of abdominal pain and dizziness after long periods of standing. A January 1988 STR notes complaints of hot spells, dizziness, shortness of breath, and bilateral mediastinal pain that lasted a short time (30 seconds) around 5 to 6 times daily. A January 1994 STR notes the Veteran’s one-month history of chest pain and reports that it also occurred during running or physical exercise; costochondritis and a flow murmur was assessed based on physical examination. On January 1994 separation examination, the Veteran reported she was having a lot of chest pains. STRs received pursuant to the August 2018 Board remand show complaints of chest pain continued while she was in the Army Reserves. On April 1999 Army Reserve examination, her heart was normal on clinical examination; in a corresponding report of medical history, she reported occasional, infrequent, and very brief episodes of chest pain and a heart murmur. An August 2003 private treatment record notes a one-year history of non-radiating chest pain with dizziness while running; she was referred to a cardiologist. On October 2003 retention examination, the physician noted complaints of chest pain increased by running and a history of dizziness; a physical profile was issued for chest pain/pressure, noting the Veteran needed a cardiac evaluation. On October 2003 cardiac evaluation, she reported chest pain when she finished exercising, and that she runs three times a week, gets tightness in her chest and becomes a little dizzy and becomes short of breath when she stops, which resolves after less than 5 minutes. An echocardiogram and stress echo to rule out valvular heart disease and ischemic heart disease were ordered. A December 2003 private echocardiogram report found a subaortic membrane with significant subaortic stenosis. In March 2005, a permanent physical profile was issued, in part, for subvalvular aortic stenosis from apparent subvalvular membrane and mild-moderate aortic insufficiency; she was cleared for modified aerobic conditioning including walking at her own pace and distance. A June 2008 Physical Evaluation Board (PEB) noted that in the view of the chronic nature of subaortic stenosis and a Commander’s statement that she does not participate in the APFT program due to her condition, it was not clear how she could be cleared for the APFT walk; she was found to be unable to perform the preponderance of her responsibilities within the limits of her profile without creating an unreasonable risk to her health. On appeal of the June 2008 PEB, a July 2009 PEB found the Veteran fit for service based on a review of her medical records and her sworn testimony, noting her physical profile permits an APFT alternative aerobic event. A July 2008 memorandum letter associated with the July 2008 PEB determined that the Veteran’s case should have been adjudicated as a duty related case (due to her currently being on active orders and having more than 8 years of active duty time). A January 2009 statement of medical examination and duty status notes the Veteran began to have severe chest pains after exercising during physical training and became lightheaded, dizzy, short of breath, and disoriented. It was noted the disease was not incurred in line of duty as it was a prior condition. The August 2018 Board remand ordered verification of all additional periods of active duty service identified by the Veteran and that she should be advised of any alleged periods of active duty that remain unverified. While she identified additional active duty periods between May 2008 to June 2009, and the AOJ obtained DFAS payroll records for that time period, it did not verify all periods of her active duty service in the Army reserve or notify her if any periods that remained unverified. Additionally, the August 2018 Board remand ordered a medical advisory opinion that addressed whether her chest pain complaints and diagnosis in active duty service were early manifestations of an underlying cardiac disability now shown. On November 2019 VA examination, valvular heart disease and subaortic stenosis were diagnosed. The Veteran reported she initially presented with chest pain, dizziness, shortness of breath, and fatigue prior to being evaluated (and diagnosed) by a cardiology specialist and reports she continues to have chest pain, dizziness, and shortness of breath with activity. The examiner opined the current heart disability is less likely than not related to service, noting the STRs support that the Veteran had a pre-existent heart murmur (first documented in 1984). As noted earlier, the Veteran is entitled to the presumption of soundness on entry in service with respect to a heart disability. The examiner noted that if manifestations of an aortic stenosis at 22 years old were found on enlistment, it would have already been present before enlistment to service; the examiner explained that a subvalvular stenosis may be congenital or an acquired defect that progresses over time. Whether a subvalvular stenosis is a congenital defect or disease or an acquired defect is a critical factor in determining whether service connection may be warranted. Additionally, the examiner did not address whether the Veteran’s complaints in service (to include chest pain during running or physical exertion, shortness of breath, and dizziness) were early manifestations of an underlying cardiac disability (that if acquired, was incurred in service, and if congenital increased during service beyond natural progression. Accordingly, the opinion is not fully responsive to the Board’s remand directives, and corrective action (development for a more complete medical advisory opinion) is necessary. See Stegall v. West, 22 Vet. App. 268, 271 (1998). The matter is REMANDED for the following: 1. Arrange for service department verification of all (not yet verified) alleged periods of the Veteran’s active duty service. The appropriate service department should be asked to verify each additional period of active duty service she identifies. She should be advised of any alleged periods of active duty she identifies that remains unverified (and that it will be assumed that if she does not identify further periods of active duty (ACDUTRA) and they are not otherwise shown in the record, that there were none. 2. Then, arrange for the Veteran’s record to be forwarded to an appropriate clinician (e.g., an internist or cardiologist) for review and a medical advisory opinion regarding the nature and likely etiology of her current cardiac disability. [If further examination of the veteran is deemed necessary for an opinion sought, such should be arranged.] The consulting provider should respond to the following: (a.) Is the Veteran’s currently diagnosed heart disability a congenital disease OR a congenital defect or is it an acquired disability? (b.) If the heart disability is a congenital disease, is there evidence that renders it undebatable from a medical standpoint it did not increase in severity during service (if so, identify such evidence)? (c.) If the heart disability is a congenital defect, was any disease or injury superimposed on it during or by service (and if so, identify when and how such occurred, i.e., due to disease, injury, or event therein)? Describe any superimposed (in or by service) pathology (and related impairment) in detail. (d.) If the heart disability is not a congenital (but instead an acquired) disability is it at least as likely as not (a 50% or better probability) that it was incurred in, or aggravated by (increased in severity beyond natural progression during) the Veteran’s active duty service. The rationale provided should discuss whether the complaints of chest pain, shortness of breath, and dizziness in service would not have been an early manifestation of an acquired heart disability during service? All opinions must include rationale. GEORGE R. SENYK Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Naumovich, 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.