Citation Nr: 21002784 Decision Date: 01/14/21 Archive Date: 01/14/21 DOCKET NO. 17-28 141 DATE: January 14, 2021 ORDER Entitlement service connection for a heart condition, to include mitral valve prolapse, including as due to herbicide exposure, is denied. FINDINGS OF FACT 1. The Veteran is presumed to have had herbicide agent exposure during service in the inland waters of the Republic of Vietnam during the Vietnam era. 2. The Veteran does not have ischemic heart disease. 3. The Veteran’s heart condition, to include mitral valve prolapse, was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease. CONCLUSION OF LAW The criteria for service connection for a heart condition to include mitral valve prolapse are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1116, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran had active service in the United States Navy from June 1965 to October 1968, including on the USS Caroline County LST 525 while it operated in the inland waterways of the Republic of Vietnam, with additional reserve service. This case comes to the Board of Veterans’ Appeals (Board) on appeal from an Agency of Original Jurisdiction (AOJ) decision dated in September 2013. This case was previously remanded to the AOJ in February 2020, for additional development, and was subsequently returned to the Board. The Veteran's representative was given an opportunity to provide a written informal hearing presentation (IHP). By a letter to the Veteran's representative in December 2020, the Board advised them that the Board previously notified them that this appeal had been assigned to them in excess of 120 days and requested submission of an IHP. The representative was advised that since the deadline to submit an IHP has passed, the case would be reassigned to the Board to adjudicate the appeal. As written argument has not been received from the Veteran's representative, the Board will proceed with adjudication. 1. Service connection for a heart condition, including as due to herbicide exposure The Veteran contends that he has a current heart condition, to include mitral valve prolapse, due to Agent Orange exposure during service in Vietnam. In May 2017, he reported undergoing coronary bypass surgery and mitral valve surgery, and contended that both medical conditions are due to Agent Orange exposure. In August 2020 he stated that he was diagnosed with a mitral valve defect at a VA facility in 1999 and it was attributed to Agent Orange. The Board has construed his claim of service connection for a heart condition to include ischemic heart disease (IHD). See Brokowski v. Shinseki, 23 Vet. App. 79, 86-87 (2009); Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). 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-elements required to establish service connection are: (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). Certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). If a Veteran served in the Republic of Vietnam during the Vietnam era, he is presumed to have been exposed to certain herbicide agents, including Agent Orange. U.S.C. § 1116(f); 38 C.F.R. § 3.307 (a)(6)(iii). If a Veteran was exposed to an herbicide agent during active military, naval, or air service, certain diseases, including ischemic heart disease (IHD), may be service connected if the requirements of 38 U.S.C. § 1116 and 38 C.F.R. § 3.307 (a)(6)(iii) are met, even though there is no record of such disease during service. 38 C.F.R. §§ 3.307 (d), 3.309(e). IHD includes, but is not limited to acute, subacute, and old myocardial infarction, atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery, and stable, unstable, and Prinzmetal’s angina. 38 C.F.R. § 3.309 (e). For purposes of this section, the term IHD does not include hypertension or peripheral manifestations of arteriosclerosis such as peripheral vascular disease or stroke, or any other condition that does not qualify within the generally accepted medical definition of ischemic heart disease. Id., Note 2. The National Personnel Records Center has confirmed that the Veteran served in the U.S. Navy aboard the USS Caroline County LST 525 which was in the official waters of the Republic of Vietnam in late 1967 and 1968. All vessels with the designation LST (Landing Ship, Tank) were operating primarily or exclusively on Vietnam’s inland waterways. Moreover, during the pendency of the appeal, the Blue Water Navy Vietnam Veterans Act of 2019 (BWN Act), was enacted, and provides that a veteran who, during active military, naval, or air service, served offshore of the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. 38 U.S.C. § 1116A (b) (effective January 1, 2020). Notwithstanding any other provision of law, for purposes of this section, the Secretary shall treat a location as being offshore of Vietnam if the location is not more than 12 nautical miles seaward of a line commencing on the southwestern demarcation line of the waters of Vietnam and Cambodia and intersecting a list of specified points. 38 U.S.C. § 1116A (d). The Board concedes the Veteran’s exposure to an herbicide agent while serving in Vietnam during the Vietnam era. 38 U.S.C. § 1116; 38 C.F.R. § 38 C.F.R. § 3.307 (a)(6)(iii). The Board previously remanded this case for a medical opinion as to whether the Veteran has a current diagnosis of IHD (a presumptive condition), and as to whether any other current heart condition is related to service, to include as a result of exposure to an herbicide agent during his service in the inland waters of the Republic of Vietnam. The Veteran has stated that he underwent coronary bypass and mitral valve surgery in May 2015 at a private hospital. Such records are not on file, and the AOJ requested that he submit or identify such records, but he has not done so. The Board notes that the duty to assist is not a one-way street. Wood v. Derwinski, 1 Vet. App. 190 (1991). The Veteran has a current diagnosis of mitral valve disease as evidenced by an October 2001 echocardiogram and a May 2020 VA medical opinion. Cardiovascular-renal disease is an enumerated condition under 38 C.F.R. § 3.309(a); Walker, 708 F.3d 1331. However, the disability was not shown as chronic in service, did not manifest to a compensable degree within a presumptive period, and was not noted in service with attributable continuity of symptomatology. VA treatment records show the Veteran was not diagnosed with mitral valve prolapse syndrome until October 2001, decades after his separation from service and decades outside of the applicable presumptive period. Service treatment records are entirely negative for a heart condition, and his heart was clinically normal on medical examination in October 1972. Chest X-ray studies dated in June 1969 and March 1972 were negative. In an October 1972 report of medical history, the Veteran denied a history of heart trouble. He reported occasional chest pain, but the reviewing examiner indicated that it was apparently muscular in nature, with no current disability. VA outpatient treatment records reflect that the Veteran complained of chest pain in April 1993. The diagnostic impression was atypical chest pain. A Quantitative Exercise Thallium Tomography study was performed in April 1993 for his complaints of chest pain on exertion and coronary artery disease (CAD). After the test was performed, the examiner indicated that there was no electrocardiogram evidence of ischemia, and the Thallium study showed normal variant apical and inferior wall thinning, but was negative for myocardial infarction or ischemia. An October 1993 treatment note reflects that the Veteran was seen for gastritis, and reported that he ran five miles per day. The examiner noted that the Veteran underwent a stress thallium study in April 1993 that showed no evidence of ischemia. Contrary to the Veteran’s recent contentions, VA medical records dated from 1998 to 2000 are negative for a heart condition, despite treatment for other medical problems. An October 2001 VA echocardiogram showed mitral valve prolapse, and an October 2001 doppler study showed severe mitral regurgitation. In January 2002 he was diagnosed with mitral valve prolapse syndrome with severe mitral regurgitation. The Veteran does not contend, and the evidence does not reflect, that he had continuous symptoms of a heart condition since service. In his October 2011 claim, he stated that his mitral valve prolapse began in 2001. The Board finds that continuity of symptomatology is not shown. The Board also finds that the Veteran does not have a diagnosis of IHD. See October 2001 echocardiogram, VA outpatient treatment records, and May 2020 VA examination. As there is no evidence of IHD, service connection is not warranted on a presumptive basis due to presumed exposure to an herbicide agent. 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307, 3.309. Service connection for a heart condition may still be granted on a direct basis; however, the preponderance of the evidence is against finding that a medical nexus exists between the Veteran’s heart condition, including mitral valve disease, and an in-service injury, event or disease. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303. The May 2020 VA examiner opined that the Veteran’s mitral valve disease is not at least as likely as not related to an in-service injury, event, or disease, including exposure to an herbicide agent. The rationale was that a review of the medical record and service treatment records shows no evidence of the diagnosis or treatment for any ischemic heart condition while on active duty or within one year of separation. The Veteran has been diagnosed with mitral valve disease (prolapse and regurgitation) more than 30 years after separation, and valvular heart disease has not been associated with herbicide exposure. There is no competent evidence of record linking any current heart condition with service. While the Veteran believes his heart condition is related to an in-service injury, event, or disease, including exposure to an herbicide agent, he is not competent to provide a nexus opinion in this case. This issue is also medically complex, as it requires specialized medical education, knowledge of the interaction between multiple organ systems in the body, and the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. S. L. Kennedy Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. L. Wasser, 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.