Citation Nr: 21064717 Decision Date: 10/21/21 Archive Date: 10/21/21 DOCKET NO. 20-04 362 DATE: October 21, 2021 ORDER Entitlement to service connection for a heart disorder diagnosed as non-ischemic cardiomyopathy, heart valve replacement, and ascending aortic aneurysm, due to service-connected non-Hodgkin's lymphoma, is granted. FINDING OF FACT The most probative evidence shows that the Veteran's heart disorder is proximately due to chemotherapy necessitated by his service-connected non-Hodgkins lymphoma. CONCLUSION OF LAW The criteria for entitlement to service connection for a heart disorder diagnosed as non-ischemic cardiomyopathy, heart valve replacement, and ascending aortic aneurysm, to include as due to service-connected non-Hodgkin's lymphoma, are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.304. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from May 1969 to April 1974, from November 1990 to May 1991, from October 2001 to November 2001, and from January 2003 to June 2003. He is a Veteran of the Vietnam Era and the Gulf War Era, including service in the Republic of Vietnam from November 1970 to October 1971 and in Southwest Asia from January 1991 to March 1991, and received the Air Medal with Bronze Star among other commendations, and the Legion of Merit Citation. This matter comes before the Board of Veterans' Appeals (Board) on appeal from June 2018 and July 2019 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO), the agency of original jurisdiction (AOJ). Favorable Findings identified in the July 2019 rating decision include: The claimed primary disability is service-connected. The Veteran is service connected for non-Hodgkin lymphoma effective February 5, 2009. The Veteran has been diagnosed with a disability. The VA examination conducted May 14, 2018, diagnosed heart valve replacement with ascending aortic valve aneurysm. 1. Entitlement to service connection for a heart disability diagnosed as cardiomyopathy, heart valve replacement, and ascending aortic aneurysm, to include as due to service-connected non-Hodgkin's lymphoma Service connection 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). Service connection may also be granted on the basis of a post-service initial diagnosis of a disease, where the physician relates the current condition to the period of service. 38 C.F.R. § 3.303(d). Service connection may be established on a secondary basis for a disability that is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Service connection on a secondary basis is warranted if there is (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus (i.e., link) between the service-connected disability and the current disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995). Analysis The Veteran asserts that his heart disability is due to his treatment for service-connected non-Hodgkin's lymphoma. He has been diagnosed with non-ischemic cardiomyopathy, heart valve replacement, and ascending aortic aneurysm. The first two elements to establish secondary service connection are therefore met. The remaining issue is whether the medical evidence establishes a nexus between the Veteran's service-connected non-Hodgkin's lymphoma and his heart disorder. In June 2017 the Veteran submitted a statement noting that service connection was granted for non-Hodgkin's lymphoma on a presumptive basis due to his exposure to Agent Orange. He received chemotherapy treatments for non-Hodgkin's lymphoma in 2009 and 2010. A heart murmur was identified thereafter. He stated that echocardiograms indicated problems with the muscles in his heart and that the aortic valve did not close properly. He stated that his oncologist told his heart surgeon that some of the medications received during chemotherapy for non-Hodgkin's lymphoma can cause heart muscle damage. In December 2017 the Veteran submitted a statement indicating that he had undergone open heart surgery for a valve replacement and an aneurysm repair. In February 2018 medical records were submitted showing aortic valve regurgitation since 2011, mild to moderate with normal LV function until 2017 when an echocardiogram indicated a decline of his ejection fraction (EF) to 35-40% and severe aortic regurgitation. A cardiac MRI scan showed a severely dilated left ventricle. He was referred for valve replacement. The preoperative diagnosis was indicated as aortic valve insufficiency and ascending aortic aneurysm. Left heart catheterization demonstrated no evidence of obstructive coronary disease. The Veteran underwent aortic valve replacement and gel weave graft replacement of the ascending aorta. The Veteran was afforded a VA examination in May 2018. The examiner noted diagnoses of heart valve replacement and ascending aortic aneurysm. He stated that he had lymphoma in 2009 and believes the chemotherapy caused heart damage. The Veteran reported that his provider heard a murmur which prompted an evaluation by Cardiology. He stated that he was followed the following years with echocardiograms in 2012, 2014, and 2016 until his ejection fraction became low necessitating the need for valve replacement. The examiner noted the cardiovascular side effects of Rituximab: Very common (10% or more): Hypotension (10%); Common (1% to 10%): Hypertension, orthostatic hypotension, myocardial infarction, arrhythmia, atrial fibrillation, tachycardia; Uncommon (0.1% to 1%): Left ventricular failure, supraventricular tachycardia, ventricular tachycardia, angina, myocardial ischemia, bradycardia; Very rare (less than 0.01%): Heart failure, vasculitis (predominately cutaneous), leukocytoclastic vasculitis. The examiner noted the Indication for Operation: He underwent preoperative evaluation with transthoracic echocardiography and subsequent CT scan imaging, which demonstrated interval enlargement of his ascending aorta. He underwent left heart catheterization, which demonstrated no evidence of obstructive coronary disease. The examiner noted that the Veteran's heart conditions did not qualify within the generally accepted definition of ischemic heart disease. The examiner noted that the etiology of his heart condition was undetermined. He noted that continuous medication is required for control of the Veteran's heart condition, specifically metropolol, a beta-blocker, and baby ASA. The examiner noted there is evidence of cardiac hypertrophy and cardiac dilatation per echocardiogram in September 2017. Left ventricular ejection fraction was noted as 40 percent; left ventricular systolic global function moderately decreased. The examiner remarked that a 3-year study found evidence that patients receiving radiotherapy and chemotherapy for lymphoma are predisposed to early development of atherosclerosis. In 96 patients, the investigators found increased intima-media thickness at 1-year follow-up; thickness had decreased at 3-year follow-up, but reduction in flow-mediated dilatation measured in the patients at 1 year had not improved by the 3-year examination. The examiner opined that the claimed condition of aortic valve insufficiency was less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service connected non-Hodgkin's lymphoma. The rationale was as follows. A review of the Veteran's medical file shows a history of aortic valve insufficiency and ascending aortic aneurysm and does not show evidence of coronary artery disease. A review of the literature shows chemotherapy side effects may increase the risk of heart disease, including weakening of the heart muscle (cardiomyopathy) and rhythm disturbances (arrhythmias). Certain types of chemotherapy also may increase the risk of heart attack. Treatment with angiogenesis inhibitors and certain other targeted medications has been linked to high blood pressure (hypertension). Aortic valve insufficiency and Ascending Aortic Aneurysm are not listed among the conditions resulting in heart damage from chemotherapy drugs. Therefore, the claimed condition of Aortic Valve Insufficiency and Ascending Aortic Aneurysm were less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service connected condition non-Hodgkin's lymphoma. The Veteran submitted a statement in June 2018. He stated that he submitted his claim because he believes that his heart issues are directly related to his chemotherapy treatment necessitated by his service connected non-Hodgkin's lymphoma, which was presumptively caused by exposure to Agent Orange in Vietnam. He stated that his claim is based on a history of illness. He stated that he has documented that he flew helicopters in Vietnam from 1970 to 1971. He underwent chemotherapy treatment for non-Hodgkin's large cell lymphoma. VA determined that this illness was connected to his exposure to Agent Orange while serving in Vietnam. He stated that when he was undergoing chemotherapy, his doctors informed him that the treatment could affect various organs including his heart. In 2011, he was diagnosed with a heart murmur and underwent a series of echocardiograms over the course of seven years until it was determined that he needed valve replacement and that he had an aneurysm on his ascending aorta. He stated that he left ventricular ejection fraction dropped from 55-60 percent before the chemotherapy to 35-30 percent. Subsequent to his open heart surgery, the Veteran stated he is still experiencing arrythmias. In October 2018, the Veteran submitted a statement reiterating that he served in the Republic of Vietnam and was exposed to Agent Orange. The Veteran asserted that his non-Hodgkin's lymphoma is service connected and his cardiomyopathy is related to the chemotherapy drugs given to him as treatment for this service connected condition. He also stated that he served in Desert Storm in Southwest Asia, operating in areas affected by oil fires and other toxic gases. The Board notes that thereby, the Veteran raised another theory of service connection. In October 2018, the Veteran's cardiologist submitted a medical opinion stating as follows: I care for [the Veteran] at the University of Virginia Health System. As you know he is a 72 y.o. male who has non-ischemic cardiomyopathy which is due to the anthracycline therapy that he received in the setting of lymphoma. The chemotherapy damaged his ventricular myocardium leading to his reduced EF. Additionally, he has a history of aortic regurgitations s/p 29mm St Jude trifecta bioprosthetic AVR with graft replacement of ascending aorta on 9/1/2017. In January 2020, the Veteran submitted a statement noting that his ejection fraction degradation precipitated his open heart surgery. He stated that the chemotherapy for his service connected non-Hodgkin's lymphoma resulted in damaged walls of his heart. While the Veteran is competent to report the timing of his surgery to his ejection fraction degradation, and the Board finds such statement to be credible, the Veteran is not competent to state that chemotherapy resulted in damage to his heart. Kahana v. Shinseki, 24 Vet. App. 428(2011). Nonetheless, his cardiologist has opined that the Veteran's heart disorder is related to chemotherapy he underwent for his service-connected non-Hodgkin's lymphoma. As an initial note, the Board finds that were it not for the Board granting service connection on a secondary basis, a remand would be required for a new medical examination and opinion to determine whether the Veteran's heart disorder is directly related to service, including as due to herbicide agent exposure in Vietnam and exposure to oil fires and other toxic gases in Southwest Asia. The May 2018 examination and opinion failed to adequately address the Veteran's lay statements, and did not relate the cited medical literature to the Veteran's specific condition. In addition, the examiner noted that the etiology of the Veteran's heart condition was undetermined but did not explain why that was so. Further, the May 2018 examination preceded the Veteran's statement asserting that his heart disorder is related to his service in Southwest Asia, which raised a new theory of service connection. Such remand however is unnecessary in light of the Board's decision to grant service connection as secondary to the Veteran's service-connected non-Hodgkin's lymphoma. The Court of Appeals for Veterans Claims held in Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) that the probative value of a medical opinion primarily comes from a physician's reasoning. A medical opinion must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Board finds the May 2018 VA examination and opinion too general in scope and that the examiner did not adequately address the Veteran's specific circumstances as related to the evidence of record, including medical evidence, lay evidence, and the cited study and medical literature. The examiner found the etiology for the Veteran's claimed heart disorder to be "undetermined" and offered no explanation for that conclusion, nor any alternative causative theory. In addition, the examiner did not adequately address the chemotherapy that the Veteran received in treatment of his service connected non-Hodgkin's lymphoma. Further, the examiner did not relate the cited small medical study and literature to the Veteran's specific circumstances. Medical treatise evidence can, in some circumstances, constitute competent medical evidence. 38 C.F.R. § 3.159(a)(1). However, such evidence must "not simply provide speculative generic statements not relevant to the [claimant]'s claim." Wallin v. West, 11 Vet. App. 509, 514 (1998). This examination and opinion are therefore entitled to low probative value. The Board further notes that many studies have been conducted involving anthracycline cardiotoxicity, including a December 2017 Study published by the American College of Cardiology. https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2017/12/21/14/55/anthracycline-cardiotoxicity-an-update. The Board includes this study to further support the observation that the Veteran's cardiologist is in the best position to opine as to whether chemotherapy for his service-connected non-Hodgkin's lymphoma proximately caused his specific heart disorder in his individual circumstances. Therefore, the Board finds his opinion is entitled to greater probative value than the more general opinion of the VA examiner and provides the requisite medical nexus to warrant service connection for a heart disorder diagnosed as non-ischemic cardiomyopathy, heart valve replacement, and ascending aortic aneurysm. Michael J. Skaltsounis Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Debra B. McLoughlin, 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.