Citation Nr: 21001786 Decision Date: 01/11/21 Archive Date: 01/11/21 DOCKET NO. 15-27 856 DATE: January 11, 2021 REMANDED The issue of entitlement to service connection for bicuspid valve prolapse with heart valve replacement and congestive heart failure is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1991 to June 1994. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In January 2019, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. The Board previously remanded this appeal in June 2019. Unfortunately, the Board finds that the issue of entitlement to service connection for bicuspid valve prolapse with heart valve replacement and congestive heart failure requires additional remand for an addendum to the October 2020 opinion. In this regard, while a VA examiner provided a thorough and detailed opinion in October 2020, explaining that the Veteran’s bicuspid valve prolapse was a congenital defect and that its degeneration due to stenosis was a disease that was not aggravated by service, the Board finds that clarification is needed as to whether the Veteran had symptoms of his heart condition in service, particularly just before separation. Specifically, while the examiner concluded that the Veteran’s heart condition did not first clinically manifest in service because of an absence of a heart murmur in the service treatment records (STRs) and because the STRs did not show symptoms of dyspnea and chest pain, he did not explain whether the Veteran’s symptoms of dizziness, headaches, and fatigue in the STRs were caused by his bicuspid aortic valve. In the Veteran’s case, STRs show that in the weeks/months leading up to separation, the Veteran had intermittent episodes of dizziness, fatigue, and orthostatic nausea and headaches. On his May 1994 separation examination, the Veteran reported a history of dizziness or fainting spells, and the examiner noted headaches and dizziness of unknown etiology. Following his separation examination, STRs show that the Veteran continued to have episodes of dizziness assessed as orthostasis in May 1994. While the Board does not presume to associate the Veteran’s symptoms with his heart condition, it finds that clarification is needed given general medical evidence suggesting an association. For example, according to the Mayo Clinic, feeling faint or dizzy with activity, and fatigue, especially during times of increased activity, can be symptoms of aortic valve stenosis. See https://www.mayoclinic.org/diseases-conditions/aortic-stenosis/symptoms-causes/syc-20353139 (last checked December 2020). Additionally, medical literature indicates that those with aortic stenosis are at an increased risk for orthostatic hypotension. See, e.g., https://www.ncbi.nlm.nih.gov/books/NBK448192/ (last updated November 2020). Given the foregoing, and because the Board previously asked about that specific evidence in its prior June 2019 remand, the Board finds that an addendum opinion should be sought.] The matter is REMANDED for the following action: Return the claims file to the October 2020 examiner or forward the Veteran’s claims file to an appropriate clinician for a medical opinion about the nature and etiology of the Veteran’s bicuspid valve prolapse with replacement and congestive heart failure. After reviewing the claims file and the October 2020 opinion, and performing a physical examination if deemed necessary, the clinician should address the following: (a.) Is the Veteran’s bicuspid valve prolapse considered a congenital defect? For purposes of answering this question, the examiner is asked to consider a congenital defect to be a condition that is static in nature, such that it is incapable of improvement or deterioration. Alternatively, is the Veteran’s bicuspid valve prolapse considered a congenital disease? In answering this question, the examiner is asked to consider a congenital disease to be a condition that is progressive in nature, such that it can worsen over time. (b.) If it is determined that the bicuspid valve prolapse is a congenital defect, was there additional disability superimposed upon that congenital defect during the Veteran’s service or lifetime? If so, is it at least as likely as not that the superimposed disability was related to any event or injury during the Veteran’s service? Please explain why or why not. (c.) If it is determined that the bicuspid valve prolapse is a congenital disease, is it at least as likely as not that the condition is related to service? Did it first manifest in service? In answering this question, please discuss the significance of the need for surgery approximately one year after the separation from service, and whether this suggests that the clinical onset of the condition occurred in service. If the condition pre-existed service, did it progress at an abnormally high rate due to service? In providing the foregoing opinions, the clinician should address the Veteran’s testimony regarding research from the Mayo Clinic indicating that extreme physical exertion (such as PT in the military) worsens the heart condition; his assertions that blood pressure readings and complaints of chronic dizziness, nausea, fatigue, and headaches in service (as detailed in STRs dating from January 1994 on) were manifestations of his heart condition; a May 1994 service treatment record noting several episodes of dizziness over the past 6 weeks and an assessment of orthostasis; the January 2019 private physician’s statement noting that the Veteran’s condition gradually developed over a period of years prior to its discovery in 1995; the Mayo Clinic article noting symptoms of aortic stenosis to include dizziness and fatigue, particularly with activity; and, the medical literature noting those with aortic stenosis to be at an increased risk for orthostatic hypotension. The clinician must provide a complete rationale for any opinion rendered. If the clinician cannot provide an opinion without resorting to speculation, he/she should explain why an opinion cannot be provided (e.g., lack of sufficient information/evidence, the limits of medical knowledge, etc.).] S. C. Krembs Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Fagan, Aileen 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.