Citation Nr: 21007322 Decision Date: 02/09/21 Archive Date: 02/09/21 DOCKET NO. 16-15 690 DATE: February 9, 2021 REMANDED Entitlement to service connection for a heart condition is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1969 to December 1970. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a July 2012 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. The Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge in April 2018. A transcript of the hearing is of record. The Board remanded this matter in September 2018. Entitlement to service connection for a heart condition is remanded. Pursuant to the September 2018 Board remand, a VA examination and opinion was obtained in November 2019. In the November 2019 VA examination, diagnoses of status post mitral valve repair and atrial fibrillation were noted. The Veteran gave a history of the condition beginning around 1970 during a doctor’s examination, where a heart murmur was discovered. In a separate November 2019 VA opinion, the examiner opined that the Veteran’s heart condition was less likely than not related to service. The examiner reviewed September 23, 1994, October 19, 1994, and May 30, 2006 treatment records, and reasoned that there were no medical records showing diagnosis or treatment for the heart condition during active duty. There were no known exposures to herbicides that would cause mitral valve injury or afib. In a second November 2019 VA opinion, the examiner opined that the Veteran’s heart condition was less likely than not related to service. The examiner reviewed September 23, 1994, October 19, 1994, and May 30, 2006 treatment records, and reasoned that there were no medical records showing diagnosis or treatment for the heart condition during active duty. The examiner noted that the Veteran said he suffered from illness with chill, fever, dyspnea, and chest pain in service in 1970 for several weeks, but did not seek medical attention, which did not indicate rheumatic fever. The examiner stated that this did not correlate to a heart condition as this would have required acute medical attention to resolve the heart condition. In a third November 2019 VA opinion, the examiner opined that the Veteran’s heart condition was less likely than not related to service. The examiner reviewed September 23, 1994, October 19, 1994, and May 30, 2006 treatment records, and reasoned that there were no medical records showing diagnosis or treatment for the heart condition during active duty. The examiner noted that the Veteran was placed on a rheumatic fever prophylaxis upon entering service which could have accounted for his illness with chill and fever for several weeks, for which he did not seek medical attention. The Veteran also had bronchitis with dyspnea and chest pain in April 1970. However, this did not correlate to his current heart condition relating to the mitral valve as he suffered on September 23, 1994, from bacterial endocarditis, which required acute treatment. Therefore, the current mitral valve heart condition was incurred more than 15 years after service in Vietnam, and had no correlation to the symptoms experienced in service. Initially, the Board notes that the examiner said he reviewed three different treatment records. This does not indicate that all treatment records were reviewed. Therefore, the Board finds the November 2019 VA opinions to be inadequate. Also, in a July 1978 treatment record, only 8 years following separation from service, the Veteran was seen for a noninvasive cardiologic evaluation. It was noted that he was seen in February 1978 for possible prolapse of the mitral valve. It was determined that the carotid pulse tracing revealed normal findings. There was normal A wave and normal first and second heart sounds. There was a mild to late systolic murmur beat recorded in the third and fourth heart sounds. There was evidence of prolapse of the posterior mitral leaflet during mid to late systolic. There were additional findings that are not as legible. The Board finds that the November 2019 VA examiner did not address these findings. Therefore, on remand, the examiner must discuss these findings that the Veteran was seen for a heart condition within 8 years of separation from service. Thus, the Board finds that a remand is warranted to obtain the medical literature referred to by the Veteran, as well as an addendum VA opinion regarding the etiology of the Veteran’s heart condition. The matters are REMANDED for the following actions: 1. Obtain a VA opinion from an appropriate examiner to determine the etiology of the Veteran’s heart condition. The claims file and a copy of this remand must be made available for review. Following a review of the pertinent evidence, the examiner must determine the following: (a) Discuss the medical reasoning of why the Veteran was placed on a program of rheumatic fever prophylaxis upon entering service. (b) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran had rheumatic fever in service. The examiner must consider and discuss the Veteran’s statement of an unreported illness during service, in which the Veteran suffered fever and chills, but did not seek medical attention. The examiner should also discuss the treatment for bronchitis with dyspnea and chest pain in April 1970. (c) Whether it is at least as likely as not (50 percent or greater probability) that any heart condition is related to service, to include exposure to herbicides. (d) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s heart condition is related to service, to include any viral or respiratory illness suffered during service. The examiner must consider and discuss the treatment for bronchitis with dyspnea and chest pain in April 1970, as well as the heart examination findings including heart sounds in October 1970. A clear rationale must be provided for all opinions expressed. The examiner must consider and discuss the Veteran’s lay statements, the contention that rheumatic fever can caused mitral valve issues if not treated properly and could take up to 10 to 20 years to develop, as well as the July 1978 treatment record, showing that the Veteran was seen in February 1978, 8 years following separation from service, for a heart condition. (Continued on the next page)   If the examiner is unable to provide an opinion without resorting to mere speculation, then the examiner must state this and provide any information needed to make an opinion, if possible. 3. Thereafter, readjudicate the claim on appeal. If the benefit sought remains denied, issue the Veteran and his representative a supplemental statement of the case and provide a reasonable opportunity to respond before returning the matter to the Board for further appellate review. MICHAEL MARTIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Saudiee Brown 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.