Citation Nr: 21001979 Decision Date: 01/12/21 Archive Date: 01/12/21 DOCKET NO. 17-32 052 DATE: January 12, 2021 ORDER Entitlement to service connection for aortic stenosis is granted. REMANDED Entitlement to service connection for hypertension is remanded. FINDING OF FACT Resolving all reasonable doubt in favor of the Veteran, the Veteran’s aortic stenosis resulted from disease incurred in service. CONCLUSION OF LAW The criteria for entitlement to service connection for aortic stenosis have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from June 1976 to June 1979 and April 1985 to June 1996. The matter comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge (VLJ) in November 2020. The hearing transcript is of record. The Board notes that the RO granted service connection for varicose veins of the right lower extremity in an April 2017 rating decision. As this is a full grant of this issue, it is no longer in appellate status. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). A September 2014 medical opinion by Dr. C.H., who upon reviewing the Veteran’s service treatment records (STRs) and treatment records following separation from the service, opined that the Veteran’s diagnosed severe aortic stenosis, was most likely (a 51 percent probability or greater) caused by or a result of the Veteran’s repeated episodes of strep throat documented during service, as these can often cause severe aortic stenosis. The examiner further stated that the Veteran had multiple documented episodes of strep throat, and now has severe aortic stenosis in a trileaflet valve; as such, it is likely that the current diagnosis was caused by these episodes. A December 2014 medical opinion by Dr. J.G., who upon reviewing the Veteran’s service treatment records (STRs) and treatment records following separation from the service, opined that the Veteran’s diagnosed severe aortic stenosis resulting in mechanical aortic valve replacement was at least as likely as not (a 50 percent probability) caused by or a result of myxoid degeneration of the aortic valve could be a direct result of multiple strep infections and pneumonia, which occurred during service. The examiner further explained that there was no evidence of a bicuspid valve, and no history of aortic stenosis prior to service. Significant myxoid degeneration of the aortic valve could be the result of multiple documented strep infections and pneumonia while in service, and a likely valve endocarditis resulted from the recurrent strep infection. A November 2020 medical opinion by Dr. N.P. states that the Veteran’s aortic valve condition is related to his history of recurrent streptococcal pharyngitis and pneumonia infections during service. The opinion further states that there is no evidence of bicuspid aortic valve or a history of aortic valve stenosis prior to service. The private examiners’ opinions are probative, because they are based on an accurate medical history and provide explanations that contain clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Veteran’s STRs indicate the Veteran had various instances of strep throat, upper respiratory infection or pneumonia while in service. The Veteran also submitted an August 2014 medical opinion by Dr. S.D.; however, January 2016 correspondence from the Veteran indicates that this opinion was provisional pending surgery. Consequently, the Board gives more probative weight to the September 2014, December 2014, and November 2020 private opinions. The Veteran also underwent a March 2017 VA examination. The examiner opined that the Veteran’s aortic stenosis is less likely as not related to service, as the cardiothoracic surgeon noted bicuspid aortic valve, which is a congenital heart defect prone to later degeneration and development of aortic stenosis, and as the Veteran did not experience rheumatic fever in service. However, the Board gives more probative weight to the September 2014, December 2014, and November 2020 private opinions. The private medical opinions were authored by the Veteran’s treating cardiologists. See November 2020 Board hearing. The Veteran also testified that he did not have any heart problems prior to service, and that his childhood and in-service physicals never indicated a heart issue. Id. The Veteran’s STRs demonstrate that his in-service physical examinations note no heart conditions. The Board finds that the Veteran has a current disability of aortic stenosis that is related to in-service respiratory conditions, as noted above. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. § 3.303(a). Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran’s current aortic stenosis is related to service. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for aortic stenosis is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND The Board finds that a remand is necessary to obtain a medical opinion regarding the Veteran’s hypertension. The August 2014 medical opinion by Dr. S.D. indicates that the Veteran has diagnoses of hypertension. However, the opinion and rationale sections are ambiguous and do not adequately answer the question of whether this condition is secondary to the Veteran’s service-connected conditions of aortic stenosis or varicose veins. See April 2017 rating decision. Furthermore, January 2016 correspondence from the Veteran indicates that this opinion was provisional pending surgery. Thus, the case must be returned for an addendum opinion. The matter is REMANDED for the following action: 1. Obtain updated VA treatment records. 2. Thereafter, obtain an addendum opinion from an appropriate medical professional if the examiner is unavailable. The claims file, as updated, must be made available to and reviewed by the examiner. The examiner must opine on the following: (a) Is the Veteran’s hypertension at least as likely as not (a 50 percent probability or greater) etiologically related to (caused or aggravated by) an in-service injury, event, or disease? (b) Is the Veteran’s hypertension, at least as likely as not (a 50 percent probability or greater) proximately due to or the result of service-connected aortic stenosis or varicose veins? (c) Is the Veteran’s hypertension at least as likely as not (a 50 percent probability or greater) aggravated (increased in severity) beyond its natural progress by service-connected aortic stenosis or varicose veins? If, and only if, the examiner determines that another VA examination is necessary to provide an informed opinion, such an examination should be scheduled. A complete rationale should be given for all opinions and conclusions expressed. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and must state whether there is additional evidence that would permit the necessary opinion to be made. Nathaniel J. Doan Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Minaya, 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.