Citation Nr: 21021936 Decision Date: 04/14/21 Archive Date: 04/14/21 DOCKET NO. 15-02 365 DATE: April 14, 2021 REMANDED Service connection for aortic insufficiency.   REASONS FOR REMAND The Veteran served on active duty from July 1985 to April 1988 and from January 1993 to May 1993, with additional service in the Army National Guard. The case is on appeal from a June 2014 rating decision. In April 2018, the Veteran testified at a Board hearing. Most recently, in July 2019, the Board remanded the claim on appeal for additional development. Service connection for aortic insufficiency. The Veteran contends that he has aortic insufficiency that was aggravated by his military service. In this regard, during his April 2018 Board hearing, the Veteran reported struggling with physical fitness testing during his active duty service. He also reported being advised he should end his National Guard service due to his heart condition, but that he was allowed to continue such service for several years thereafter. During the April 2018 Board hearing, the Veteran reported experiencing reduced stamina due to this condition. After being discharged from active duty in both April 1988 and May 1993, the Veteran served in the Army National Guard. In July 1994, the Veteran was treated for strep throat and heart symptoms. In August 1994, a cardiology consultation found that the Veteran had a bicuspid aortic valve and dilated aortic root. Thereafter, in December 1995, the Veteran was treated by a private medical facility for shortness of breath, dyspepsia, weakness, and fatigue following a two mile training run. Later that month, he was diagnosed with a bicuspid aortic valve, reduced left ventricular ejection, and a prolapsed aortic leaflet resulting in moderately severe aortic insufficiency. A periodic service examination in July 1996 noted that the Veteran has an aortic condition. Subsequently, in October 1996, a medical duty review board recommended that he be found unfit for retention in the National Guard. However, the Veteran remained in the National Guard and was placed on profile limiting his required physical fitness training. He underwent surgery to replace an aortic heart valve in December 1998. During later periods, he performed physical training of walking 2.5 miles in February 2000, October 2001, and April 2003. However, a May 2003 medical retention board found that continued periods of active duty for training (ACDUTRA) may aggravate the Veteran’s heart condition and place him at unnecessary risk. Subsequently, the Veteran completed another 2.5 mile physical training walk in October 2003. The Veteran served in the National Guard through January 2005. The Veteran was afforded a VA examination in regard to this claim in October 2007 in connection with the original claim. The examiner noted the date of onset of aortic insufficiency as 1994 and that an aortic valve replacement was done in December 1998. The examiner found the Veteran’s aortic insufficiency was not aggravated by military service. Pursuant to the July 2018 Board remand, the Veteran was afforded another examination in March 2019. The Veteran reported experiencing dizziness and shortness of breath with exertion. The examiner found that the Veteran’s aortic insufficiency had its onset in 1994 and is a progression of his congenital aortic valve defect. The examiner also found that the condition was not related to his ACDTURA service. Pursuant to the July 2019 Board remand, the Veteran was afforded another examination in March 2020. However, the examiner did not provide sufficient rationale for his findings and concluded that the Veteran has not had symptoms since service without considering the Veteran’s reports of symptoms during the appeal period. Therefore, another remand is warranted to obtain a medical opinion adequately addressing the relevant medical questions. In addition, updated VA treatment records should be associated with the file. The claim is REMANDED for the following actions: 1. Obtain complete VA treatment records from September 2020. 2. After completing the records development indicated above, forward the claims file to a VA cardiologist, or other appropriate examiner, to address the nature and etiology of the aortic insufficiency. The record, to include a copy of this remand, must be made available to and be reviewed by the examiner. The examiner should provide opinions as to the following inquiries in consideration of the Veteran’s reports of relevant symptoms since March 2014, including reduced stamina: (a.) To the extent possible, identify the onset date of the Veteran’s aortic insufficiency or the relative time period that it first manifested. (b.) Provide an opinion as to whether the Veteran’s aortic insufficiency is congenital. (c.) If so, provide an opinion as to whether aortic sufficiency is a congenital disease or defect. The terms “disease” and “defect” must be interpreted as being mutually exclusive. For VA legal purposes, the term “disease” is broadly defined as any deviation from or interruption of the normal structure or function of any part, organ, or system of the body that is manifested by a characteristic set of symptoms and signs and whose etiology, pathology, and prognosis may be known or unknown. The term “defect” is defined as structural or inherent abnormalities or conditions that are more or less stationary in nature. Defects are static conditions that are incapable of improvement or deterioration, whereas diseases are capable of such progression. (d.) If aortic insufficiency is not congenital or is a congenital disease, the presumption of soundness applies in regard to the Veteran’s two periods of active duty service (July 1985 to April 1988 and January 1993 to May 1993). As such, the examiner should explain whether the condition clearly and unmistakably (i.e., medically undebatable) pre-existed either period of active duty service (which may be essentially answered in letter (a)). (e.) If aortic insufficiency did pre-exist a period of active duty service, the examiner should state whether the condition clearly and unmistakably (i.e., medically undebatable) was not aggravated during active duty service, to include ongoing symptoms of dizziness, shortness of breath, and fatigability, as due to physical fitness training or stress. Aggravation is an increase in disability beyond the natural progress of the disease or temporary flare-up. (f.) In any case, the examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran currently has aortic insufficiency, to include ongoing symptoms of dizziness, shortness of breath, and fatigability, that is related to either of the periods of active duty. (g.) If aortic insufficiency had onset after both periods of active duty service but not during a period of ACDUTRA, the examiner should provide an opinion as to whether it is it at least as likely as not that the condition increased in severity), to include ongoing symptoms of dizziness, shortness of breath, and fatigability, as a result of any subsequent period of ACDUTRA service beyond the natural progression of the disease or temporary flare-up (i.e., aggravation, to include as due to physical fitness training during. Please note a National Guard retirement points statement lists no active duty points from December 1993 to January 1996, but there are between 13 and 32 active duty points per year between January 1996 and January 1994 with none in 1998. If the examiner cannot provide some or all of the requested opinions, he or she should explain why such opinions cannot be provided. A rationale for all opinions should be expressed. RYAN T. KESSEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Jimerfield 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.