Citation Nr: 21069653 Decision Date: 11/19/21 Archive Date: 11/19/21 DOCKET NO. 17-50 069A DATE: November 19, 2021 ORDER Entitlement to service connection for bicuspid aortic valve, repair of cortication of aorta (claimed as heart disorder) is denied. FINDING OF FACT The Veteran's bicuspid aortic valve, repair of cortication of aorta, is a congenital defect without superimposed disease or injury. CONCLUSION OF LAW The criteria for service connection for bicuspid aortic valve, repair of cortication of aorta have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served with the Army National Guard of Louisiana and had a period of active duty for training (ACDUTRA) from June 1990 to July 1990. This case initially came before the Board of Veterans' Appeals (Board) on appeal from a May 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO), which denied service connection for bicuspid aortic valve, repair of cortication of aorta. In October 2019, the Board remanded the matter for further evidentiary development. The agency of original jurisdiction obtained a February 2020 opinion which, for the reasons discussed below, was adequate to decide the claim. Thus, there has been substantial compliance with the remand directives. Stegall v. West, 11 Vet. App. 268 (1998). Service Connection Service connection will be granted if the evidence demonstrates that current disability resulted from an injury or disease incurred in the active military, naval, air, or space service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). A veteran will be considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto and was not aggravated. 38 U.S.C. §§ 1111; 38 C.F.R. § 3.304 (b). However, the presumption of soundness does not apply to congenital or developmental "defects," because they are not diseases of injuries within the meaning of the applicable laws and regulations. Quirin v. Shinseki, 22 Vet. App. 390, 397 (2009); 38 C.F.R. § 3.303(c). Service connection is warranted, however, if a disease or injury is superimposed over the congenital or developmental defect during service and there is a resultant disability. See Jensen v. Brown, 4 Vet. App. 304, 306-307 (1993); VAOPGCPREC 82-90. "Congenital defects" are treated differently than "congenital diseases" in the context of VA disability compensation. A defect differs from a disease in that the former is "more or less stationary in nature" while the latter is "capable of improving or deteriorating." See Quirin v. Shinseki, 22 Vet. App. 390, 394 (2009); VA Gen. Couns. Prec. 82-90 at 2. Compensation is warranted for congenital diseases if aggravated by a claimant's military service. Id. 1. Heart Disorder The Veteran contends that he had no problems with his bicuspid aortic valve before he went on active duty. Specifically, he contends that his condition was aggravated by the intense physical training, with symptoms of pain in legs, weakness, shortness of breath, and seeing spots. See October 2017 VA Form 9, Substantive Appeal. For the following reasons, the Board finds that service connection for bicuspid aortic valve, repair of cortication of aorta is not warranted. The Veteran's service treatment records (STRs) include a June 22, 1990 entrance physical standards board proceeding finding that the Veteran was medically unfit for appointment or enlistment. The Veteran was briefly admitted to hospital for dehydration and noted to have murmur consistent with aortic stenosis. Bicuspid aortic valve with mild insufficiency was noted, with the approximate date of origin at birth. The Veteran was afforded a VA examination in April 2014. The examiner noted diagnoses of bicuspid aortic valve, and surgical correction of coarctation of the aorta. The examiner opined that the Veteran's heart condition which clearly and unmistakably existed prior to service, was not aggravated beyond its natural progression by an in-service event, injury or illness. The examiner explained that the Veteran's heart condition was detected and diagnosed during medical examination in military service. Incidental finding of heart murmur led to echo, and to diagnosis of condition. The examiner further explained that there is no indication or findings that support condition was worsened or aggravated by the Veteran's active duty service. The examiner noted the medical literature supports that coarctation of the aorta often occurs with other congenital defects, such as bicuspid aortic valve. The examiner further noted, that when mild, this condition is often not diagnosed until adulthood. The examiner did not indicate whether the Veteran's heart condition was a congenital defect or disease. The Veteran underwent another VA examination in February 2020. The examiner opined that the Veteran's heart condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that both the aortic valve and coarctation of the aorta are congenital birth defects. The examiner further explained that Merriam-Webster Defines disease as "a condition of the living animal or plant body or of one of its parts that impairs normal functioning and is typically manifested by distinguishing signs and symptoms " and a "Birth Defect" as "a physical or biochemical defect that is present at birth and may be inherited or environmentally induced". The examiner stated that as such, any birth defect is a disease but not every disease is a birth defect. Also, the examiner noted that the definitions and these attempts at drawing a distinction between a disease and a defect will serve to confound rather than clarify the issue. The examiner noted his desire to avoid falling into the trap of definitions and semantics, and that the spirit of the question is meant as a segue to a following question, which gets to the heart of the matter and that is if the Veteran's condition, whether it is a disease or a defect, was in any way aggravated by or during the service. The examiner indicated that when a cardiologist is attempting to make a diagnosis of a claimant who may or may not have a cardiac condition, the cardiologist will put the claimant through a stress test to exert the heart to elicit any latent condition that would manifest under stress. The examiner further indicated that in a sense, the rigors of the basic training served as a stress test that brought to light the latent condition of the Veteran that is the bicuspid valve and coarctation of the aorta. The examiner noted that in fact, the Veteran made a comment that, "If it wasn't for the military, I wouldn't have known what I have and who knows what could have happened?" The examiner explained the military served as a "stress test" that brought to light the Veteran's congenital condition that he was not aware of, nor was anyone else, but it did not aggravate it in any way. The examiner further explained that an aggravation of such condition would mean increasing the narrowing of the aorta or the inefficiency of the aortic valve neither of which occurred during or as a result of the service. The examiner further opined that it was less likely than not the Veteran incurred any superimposed disease or injury on such congenital defect during service. The examiner explained review of the medical records does not show the Veteran incurred any superimposed condition during the service that aggravated his underlying congenital conditions. As the February 2020 VA examiner's opinion reflects an attempt to explain the applicable medical concepts and to apply them to the particular facts of this case, and accurately characterized the evidence including consideration of the Veteran's lay statements, the opinion is entitled to substantial probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed). Moreover, there is no contrary medical opinion in the evidence of record. To the extent that the Veteran asserts that heart condition is related to service, either as a congenital disease that was aggravated or otherwise, he is competent to attest to his observations and the etiology of simple medical matters. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). He is not, however, competent to opine on complex medical matters such as the etiology of heart conditions, which are questions that relate to internal medical process that extend beyond an immediately observable cause-and-effect relationship that is of the type that the courts have found to be beyond the competence of lay witnesses. Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis). To the extent that the Veteran's statements are competent, the specific reasoned opinion of the February 2020 VA examiner is of greater probative weight than the Veteran's more general lay assertions. For the foregoing reasons, the weight of the evidence reflects that the Veteran's bicuspid aortic valve, repair of cortication of aorta, is a congenital defect without superimposed disease or injury. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Jonathan Hager Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Walker, 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.