Citation Nr: 21006022 Decision Date: 02/03/21 Archive Date: 02/03/21 DOCKET NO. 18-29 428 DATE: February 3, 2021 ORDER Entitlement to service connection for coronary artery disease (CAD) with coronary artery bypass grafting (CABG), to include as secondary to service-connected mitral and/or tricuspid insufficiency, is denied. REMANDED Entitlement to an evaluation in excess of 10 percent for service-connected mitral and/or tricuspid insufficiency is remanded. Entitlement to service connection for a respiratory condition, to include asbestosis, is remanded. FINDING OF FACT The Veteran’s CAD was not caused by or aggravated by a service-connected disability and has otherwise not been shown to be etiologically related to service. CONCLUSION OF LAW The Veteran’s CAD was not caused by or aggravated by a service-connected disability and has otherwise not been shown to be etiologically related to service. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from August 1959 to August 1961. This matter is before the Board of Veterans’ Appeals (Board) on appeal of an August 2017 rating decision of the Department of Veterans Affairs (VA). In May 2019, the Board remanded the case for further development. Stegall v. West, 11 Vet. App. 268, 271 (1998). Entitlement to service connection for CAD with CABG, to include as secondary to service-connected mitral and/or tricuspid insufficiency. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. § 1131; 38 C.F.R. § 3.303. “To establish a right to compensation for a present disability, a veteran must show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service” the so-called “nexus” requirement.” Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted on a secondary basis for a disability if it is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show that a current disability exists and that the current disability was either proximately caused or aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995). The Veteran underwent coronary bypass surgery in 2012. VA treatment records show a diagnosis of coronary artery disease and status post CABG. The Veteran was afforded a VA heart examination in May 2002. The Veteran reported dyspnea and dizziness. An impression of arteriosclerotic CAD was provided. It was noted that the arteriosclerotic CAD was not the result of his murmur that was present in service and was his primary etiology of his cardiac problem. The Veteran was afforded a VA heart examination in August 2012. The VA examiner diagnosed the Veteran, in part, with CAD, hypertensive heart disease, and status post CABG. It was noted that the Veteran experienced shortness of breath secondary to CAD, requiring CABG. Upon examination, congestive heart failure (CHF) was found. It was noted that the Veteran had more than one acute CHF episode. In an addendum dated that same month, the VA examiner noted that the Veteran’s ischemic heart disease (IHD) and CABG were not aggravated by his service-connected heart condition. The VA examiner noted that the Veteran’s congestive heart failure (CHF) was not due to his service-connected heart condition. All of his cardiac symptoms were caused by his IHD and possible his hypertension (service connection is not in effect for hypertension). His valvular condition was an incidental finding. The Veteran was afforded a VA heart examination in July 2017. The VA examiner diagnosed the Veteran, in part, with CAD and CABG. He reported experiencing severe swelling in his legs, shortness of breath with any exertional activities and difficulty walking any distance. CHF was not found. The VA examiner opined that the condition claimed was less likely than not proximately due to or the result of the Veteran’s service-connected condition. The VA examiner stated that the Veteran had CAD/IHD caused by family history, hypertension and diabetes. An ECHO, performed in June 2017, revealed the same result as an April 2012 ECHO, namely mild mitral and tricuspid insufficiency. The ejection fraction in June 2017 was more than 60 percent. The VA examiner noted that the August 2012 addendum was a valid explanation of the Veteran’s condition. The Veteran was afforded a VA heart examination in January 2018. The VA examiner diagnosed the Veteran, in part, with CAD and CABG. No CHF was found. The Veteran was afforded a VA heart examination in November 2019. The VA examiner diagnosed the Veteran, in part, with CAD and CABG. The Veteran reported occasional chest pain with numbness that radiated down his arm, occasional heart palpitations and significant fatigue. No CHF was found. The VA examiner stated that the Veteran’s heart condition may produce symptoms of heart palpitations and fatigue, although it was not possible to distinguish what level of symptomology was attributable to the nonservice-connected and service-connected heart conditions as the symptoms overlapped. The VA examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The VA examiner stated that the Veteran had developed an isolated incident of atrial fibrillation following CABG. A review of the evidence found no history or current diagnosis of CHF. CAD was the result of plaque build-up in the walls of the coronary arteries. In the Veteran, CAD led to the MI and subsequent CABG. The atrial fibrillation was likely a result of the Veteran’s cardiac surgery and electrical pathway disruption. None of these conditions were related to the Veteran’s known and service-connected history of valvular heart disease/mitral insufficiency. The Veteran’s heart valve insufficiency resulted in the valves within the heart not closing appropriately, altering blood flow through the heart. CAD affected the vessels supplying blood to the heart muscle, and was, thus, not related to the flow of blood within the heart. Although mitral valve insufficiency could lead to atrial fibrillation, in the Veteran’s case, the atrial fibrillation began following cardiac surgery and resolved after the isolated incident and without recurrence, thus making it more likely than not that it was a result of the cardiac surgery and not a progression of the mitral valve insufficiency. There was no physiological evidence to support a relationship between the Veteran’s service-connected mitral and/or tricuspid insufficiency, stable with history of heart murmur and the diagnosis of CAD, myocardial infarction (MI), CABG, or atrial fibrillation. Further, there was no physiological basis to support an aggravation of these conditions by the Veteran’s service-connected condition. The Veteran did not take medication for treatment of the service-connected condition; thus, no relationship existed between CAD, MI, CABG, HTN, or atrial fibrillation and treatment for the service-connected mitral and/or tricuspid insufficiency. In addition, the Veteran had a history of a diagnosis of hypertension. There was no physiological basis to support hypertension being caused by or aggravated by the Veteran’s service-connected mitral and/or tricuspid insufficiency. Although literature stated that mitral valve regurgitation could lead to the development of pulmonary hypertension, this form of hypertension was exclusive to the vessels in the lungs, and was a separate condition from that which the Veteran was diagnosed (hypertension). A site for a literature article was provided. Having carefully reviewed the claims file, the Board determines that the preponderance of the evidence is against the claim for service connection for CAD with CABG, to include as secondary to the service-connected mitral and/or tricuspid insufficiency. The record contains no competent opinion linking the Veteran’s heart condition to his mitral and/or tricuspid insufficiency or indicating that the Veteran’s mitral and/or tricuspid insufficiency had worsened his other heart condition. Rather, the VA examiners opined that the Veteran’s mitral and/or tricuspid insufficiency did not cause or aggravate the Veteran’s claimed CAD. The VA examiners considered the Veteran’s reported history, the records in the claims file, and the examination findings, and adequate rationales regarding direct and secondary causation were provided. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008). Further, there are no medical opinions to the contrary. The Veteran is certainly competent, as a lay person, to report symptoms of which he has personal knowledge, such as shortness of breath and fatigue, and the Board finds his account credible. See Layno v. Brown, 6 Vet. App. 465, 469-470 (1994). However, as a lay person, he is not competent to establish a medical diagnosis or show a medical etiology merely by his own assertions, as such matters require medical expertise. See 38 C.F.R. § 3.159(a)(1). The specific issue in this case, the relationship between the Veteran’s heart condition and military service and/or a service-connected disability, is a complex medical issue and thus is outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). As a lay person, he does not have the education, training, or experience to offer a medical diagnosis or an opinion as to the onset or etiology of this disability. See Kahana v. Shinseki, 24 Vet. App. 428 (2011). In light of the foregoing, the Board finds that the preponderance of the evidence is against the Veteran’s claim of service connection for CAD with CABG, because the persuasive medical evidence shows that the condition did not have its onset during active service and is not otherwise related to military service. The persuasive medical evidence further shows that the heart condition is neither caused nor aggravated by the service-connected to mitral and/or tricuspid insufficiency. As such, the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Therefore, service connection for the heart condition on a direct or secondary basis is also not warranted. REASONS FOR REMAND Entitlement to an evaluation in excess of 10 percent for service-connected mitral and/or tricuspid insufficiency In July 2017, metabolic equivalent (MET) testing symptoms were noted as dyspnea, fatigue, and dizziness. Results were noted as 1-3 METs. A January 2018 VA examination also revealed METs results of 1-3. The Veteran was afforded a VA heart examination in November 2019. It was noted that the Veteran was taking metoprolol for his service-connected heart condition. The Veteran reported experiencing heart palpitations and significant fatigue. The VA examiner diagnosed the Veteran, in part, with acute, subacute, or old myocardial infarction, valvular heart disease, mitral and/or tricuspid insufficiency and atrial fibrillation. Upon examination, it was found that the Veteran’s cardiac arrhythmia, described as atrial fibrillation, was intermittent (paroxysmal), with zero episodes in the past 12 months, as documented by EKG. It was noted that the Veteran’s heart valve condition affected the mitral valve. Mitral regurgitation was indicated. Echocardiogram results showed left ventricle ejection fraction (LVEF) at 60 percent. The wall motion was normal, and the wall thickness was abnormal and mild left ventricular hypertrophy was noted. MET testing symptoms were noted as fatigue, angina and dizziness. Results were noted as 3-5 METs. It was noted that the Veteran’s service-connected heart condition could produce heart palpitations and fatigue. As noted above, the Board has denied the claim for service connection for CAD. That said, the Veteran has a history of relatively low METs scores, and it is not entirely clear the extent to which those METs scores in total are attributable to the service-connected mitral and/or tricuspid insufficiency, as opposed to the nonservice-connected CAD. A reexamination, including a retrospective opinion as to the cause of the low METs scores, is thus required here. Entitlement to service connection for respiratory condition, to include asbestosis as a result of asbestos exposure. The Veteran claims that he has asbestosis or another respiratory/lung condition as a result of his exposure to asbestos during his period of active duty service. In a statement, dated in June 2017, the Veteran noted that he was exposed while serving on mechanized landing crafts on the Mississippi River while he was stationed at Camp Leroy Johnson in New Orleans, Louisiana. He noted that as a deckhand and a machinist, he was exposed to asbestos. The Veteran also noted that post service, he was exposed to asbestos while working on furnaces for Pratt & Whitney, for 10 years. In support of his appeal, the Veteran submitted an article indicating that “[t]he shortest latency period for asbestosis is 5 to 10 years, although often it takes 40 or more years from first exposure before the disease is diagnosed.” In this case, while the Veteran has asserted that he was exposed to asbestos both while in service and post-service, the Board find that it is unclear if the Veteran was, indeed, exposed to asbestos during his active duty service. As such, a remand is necessary to verify the Veteran’s statements. While on remand, the RO should conduct appropriate development to verify any potential exposure to asbestos during his service. Moreover, while the November 2019 and November 2020 VA examiners provided opinions as requested, it is not apparent that the November 2020 VA examiner considered VA treatment notes, within the past 5 years, that reflect x-ray and PFT results referencing scarring and lung disease consistent with asbestos exposure. As such, a supplemental opinion is warranted. The matters are REMANDED for the following action: 1. Conduct appropriate development to verify any potential exposure to asbestos during the Veteran’s service. A formal finding must be issued regarding the likelihood that the Veteran was exposed to asbestos during his active service. 2. Afford the Veteran a VA heart examination to address the symptoms and severity of his service-connected mitral and/or tricuspid insufficiency. The examiner is asked to review the claims file in conjunction with this examination, with particular attention to the VA medical reports from June 2017, January 2018, and November 2019, and is asked to perform all necessary cardiac testing (e.g., METs testing, ejection fraction). The examiner is specifically asked to opine as to the extent to which the METs findings from June 2017, January 2018, and November 2019 can be attributed to the service-connected mitral and/or tricuspid insufficiency, as opposed to the nonservice-connected CAD. To the extent that the METs findings are attributed to the CAD as opposed to the service-connected disability, the examiner should so state. If such a differentiation cannot be made, the examiner should clearly explain why. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached. The Board recognizes the practical difficulties of scheduling an examination, if needed, in view of the COVID-19 epidemic, and requests flexibility and understanding in affording the Veteran an opportunity to report for an examination. 3. Next, return the Veteran’s claims file to the examiner who provided the November 2020 VA medical opinion for an addendum opinion. If an additional examination is necessary, one should be scheduled. If the prior examiner is not available, the file must be forwarded to another similarly qualified examiner to obtain the requested opinion. The examiner is requested to provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the diagnosed respiratory disability of record had its onset during or is otherwise related to any event or injury during active duty, to include asbestos exposure. The examiner is also asked to discuss the medical findings of record, to include medical records within the past 5 years, as noted above, which indicate a finding of a respiratory disability associated with asbestos exposure. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached. [continued on next page] The Board recognizes the practical difficulties of scheduling an examination, if needed, in view of the COVID-19 epidemic, and requests flexibility and understanding in affording the Veteran an opportunity to report for an examination. A. C. MACKENZIE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A-L Evans, 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.