Citation Nr: 21064212 Decision Date: 10/19/21 Archive Date: 10/19/21 DOCKET NO. 17-28 449A DATE: October 19, 2021 ORDER Entitlement to service connection for aortic stenosis is denied. FINDING OF FACT The Veteran's aortic stenosis was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology was not established; and the disability was not otherwise etiologically related to an in-service injury or disease. CONCLUSION OF LAW The criteria for service connection for aortic stenosis are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Appellant is the surviving spouse of the Veteran who had active military service from November 1950 to November 1952. The Veteran died in June 2017. This matter comes to the Board of Veterans' Appeals (the Board) on appeal from an October 2016 rating decision in which the Agency of Original Jurisdiction (AOJ) denied entitlement to service connection for aortic stenosis. Following the Veteran's death, the AOJ granted the Appellant's substitution request in October 2017. The Appellant participated in a hearing before the undersigned Veterans Law Judge in September 2019. A transcript of this hearing is of record. Subsequently, the Board remanded the Appellant's claim to obtain a medical opinion in January 2020. The AOJ obtained the requested opinion in March 2020. The Veteran's appeal was most recently before the Board in April 2021, at which point the Board remanded it to attempt to obtain medical records. The Board notes that the AOJ requested information from the Appellant regarding the Veteran's private medical care providers in May 2021, but the Appellant did not respond to this request. The Appellant's representative indicated that it would be "futile" to make a second request. See Informal Hearing Presentation dated September 2021. Accordingly, the Board will proceed with the adjudication of the Appellant's appeal. 1. Entitlement to Service Connection for Aortic Stenosis In an October 2016 statement, the Veteran reported that, during service, he was told that he had an enlarged heart and was diagnosed with heart arrhythmia and palpitations. The Appellant has since asserted that the Veteran's active service aggravated his preexisting cardiovascular issues, including high blood pressure, dizziness and fainting spells, and frequent headaches, that were noted on his induction examination. Veterans shall be considered to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates than an injury or disease existed prior thereto and was not aggravated by such service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b); Wagner v. Principi, 370 F.3d 1089, 1092 (Fed. Cir. 2004). The presumption of soundness applies only when a disease or injury not noted upon entry to service manifests in service, and a question arises as to whether it preexisted service. Gilbert v. Shinseki, 26 Vet. App. 48, 55 (2012), aff'd 749 F.3d 1370 (Fed. Cir. 2014). In this case, there is a question as to whether the Veteran's aortic stenosis preexisted his November 1950 to November 1952 military service. At the outset, the Board notes that the Veteran's service treatment records are very limited, due to destruction in a fire. However, the record does contain the Veteran's pre-induction and separation examinations. The report of the pre-induction examination noted that the gave a history of high blood pressure, dizziness and fainting spells, and frequent or severe headaches. He denied experiencing heart palpitations or pounding heart. The portion of the report pertaining to an examination of the heart is illegible due to fire-related damage. However, it is the Appellant's contention that these symptoms were manifestations of a cardiovascular condition that preexisted the Veteran's service and was subsequently aggravated by his active service. The examiner who proffered the March 2020 VA medical opinion disagreed with the Appellant's assertion. He opined that the evidence indicates that the Veteran did not have aortic stenosis or manifestations thereof prior to active service, as the heart and vascular conditions reported are not attributable to aortic stenosis. The Board finds this medical opinion to be highly probative, as it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). As such, the Board concludes that the Veteran was sound with respect to aortic stenosis upon his entry into service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b); Wagner, 370 F.3d at 1092. However, the most competent and credible evidence of record shows that the Veteran's aortic stenosis did not manifest during his active service. During the Appellant's September 2019 hearing, she testified that the Veteran was diagnosed with an enlarged heart during service and experienced symptoms such as high blood pressure, daily fainting spells, and severe headaches. The Veteran's separation examination noted a history of hypertension for several years as well as vascular abnormalities. However, the March 2020 VA examiner considered these lay reports and concluded that they were not attributable to aortic stenosis. He explained that the development of heart palpitations and syncope signal early mortality; as such, it is "medically implausible" that the Veteran would live for another 70 years after the onset of these symptoms. As above, the Board finds this medical opinion to be of significant probative value. Nieves-Rodriguez, 22 Vet. App. at 304. Therefore, as the Veteran did not develop aortic stenosis during service, the presumption of soundness does not attach. See Gilbert, 26 Vet. App. at 52. Instead, the Board will adjudicate the appeal as one for direct or presumptive service connection. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 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). Service connection may also be granted for any injury or disease diagnosed after discharge when the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Certain chronic diseases, including endocarditis, are subject to presumptive service connection if they manifest to a compensable degree within one year from separation from service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. See 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Aortic stenosis, as a form of valvular heart disease, is considered a covered chronic disease under 38 U.S.C. § 3.309(a). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden elements is through a demonstration of continuity of symptomatology if the claimed disability qualifies as a chronic disease listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331, 1336 (Fed. Cir. 2013). As aortic stenosis is a chronic disease, service connection via the demonstration of continuity of symptomatology is applicable. Prior to his death, the Veteran had a diagnosis of aortic stenosis, as evidenced by August 2015 VA treatment records. Aortic stenosis is an enumerated condition under 38 C.F.R. § 3.309(a), as it covers all forms of valvular heart disease. Walker, 708 F.3d at 1331. The heart disability (aortic stenosis) 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. The Appellant testified that the Veteran was diagnosed with aortic stenosis in 1985; however, these records are not included in the claims file even though she was afforded the opportunity to submit them following her September 2019 hearing. Rather, the earliest reference in the record to aortic stenosis is found in VA treatment records from August 2015. Even assuming the Veteran was diagnosed with aortic stenosis in 1985 as the Appellant testified, such diagnosis occurred over three decades after his separation from service and the applicable presumptive period. While the Veteran was competent to report having experienced symptoms such dizziness, fainting, severe headaches, and heart palpitations, since service, he was not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of aortic stenosis, as it has not been shown that the Veteran had the necessary medical expertise. The issue is medically complex, as it requires knowledge of the interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). The Board gives more probative weight to the competent medical evidence of record, including the March 2020 VA medical opinion establishing that the Veteran's in-service complaints of high blood pressure, dizziness, fainting spells, severe headaches, heart palpitations, and arrhythmia were not related to his subsequent diagnosis of aortic stenosis. The rationale was that these symptoms are suggestive of mortality; thus, per the VA examiner, it would be "medically implausible" for the Veteran to live for an additional 70 years after the onset of such symptoms. As above, the Board finds that the March 2020 VA examiner's opinion is probative because it is based on an accurate medical history and provides an explanation with clear conclusions and supporting data. Nieves-Rodriguez, 22 Vet. App. at 304. Service connection for aortic stenosis 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 aortic stenosis and an in-service injury, event, or disease. 38 U.S.C. § 1110; 38 C.F.R. § 3.303; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). The March 2020 VA examiner opined that the Veteran's aortic stenosis was less likely than not related to an in-service injury, event, or disease, including his complaints high blood pressure, dizziness, fainting spells, severe headaches, heart palpitations, and arrhythmia during service. Along with his finding that the Veteran's in-service symptoms were not attributable to aortic stenosis, the examiner also explained that the Veteran's aortic stenosis was likely the result of degenerative changes associated with age. Consideration has been given to evidence and argument suggesting a correlation between the Veteran's aortic stenosis and hypertension. Service connection for hypertension has never been established. Service connection on a secondary basis under 38 C.F.R. § 3.310 would therefore be denied as a matter of law. Sabonis v. Brown, 6 Vet. App. 426 (1994). In that regard, the Board does not find that the holding in Clemons extends to the Veteran's hypertension. The Court in Clemons determined that a Veteran, as a layperson, was not competent to distinguish between competing psychiatric diagnosis, i.e. anxiety versus depression versus posttraumatic stress disorder. Whereas aortic stenosis represents a diagnosis related to the heart, hypertension is a disability related to entire vascular system. Hypertension is not a disability of the heart. The Veteran and the Appellant believe that the Veteran's aortic stenosis was related to his in-service symptoms of high blood pressure, dizziness, fainting spells, severe headaches, arrhythmia, and palpitations. However, neither the Veteran nor the Appellant in this case are competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of interpretation of complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran and the Appellant here because the record does not show that they have the medical training or credentials to make such a determination. Jandreau, 492 F.3d at 1377 n.4; see also Kahana v. Shinseki, 24 Vet. App. 428, 434 (2011). Consequently, the Board assigns more probative weight to the March 2020 VA medical opinion. Accordingly, the preponderance of the evidence is against the Appellant's claim for entitlement to service connection for aortic stenosis. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Thus, the claim must be denied. MICHAEL A. HERMAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R.M. Sachs, 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.