Citation Nr: 21022962 Decision Date: 04/19/21 Archive Date: 04/19/21 DOCKET NO. 13-31 594 DATE: April 19, 2021 ORDER Entitlement to service or secondary service-connection for atrial fibrillation with aortic valve stenosis, to include hormone treatments for prostate cancer, is denied. FINDING OF FACT The Veteran’s atrial fibrillation with aortic valve stenosis, is not etiologically related to service or secondary to any service-connected disabilities, to include hormone treatments for prostate cancer. CONCLUSION OF LAW The criteria for service-connection for atrial fibrillation with aortic valve stenosis due to service or secondary service-connected disabilities, to include hormone treatments for prostate cancer are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 1967 to July 1971. The matter comes before the Board of Veterans’ Appeals (Board) on appeal from a December 2011 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge (VLJ) in June 2016. The hearing transcript is of record. The Board remanded the claim in November 2017 and March 2020 for further development by the RO. The case was then again remanded in December 2020, because the RO obtained a March 2018 VA examination and two subsequent addendum opinions in November 2019 and August 2020, and none of these opinions adequately addressed aggravation. In addition, in the August 2020 opinion, the examiner’s report indicates a possible link between the other service-connected heart disability and the atrial fibrillation but did not provide a non-speculative opinion on this question. The Board has found that the Veteran was exposed to herbicide agents in service. See November 2017 Board Decision. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. To establish service connection on a direct basis, the record must contain: (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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Secondary service connection is warranted where a claimed disability is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). The threshold legal requirements for a successful secondary service connection claim are evidence of (1) a current disability for which secondary service connection is sought; (2) a disability already service-connected; and (3) competent evidence that the already service-connected disability caused or aggravated the disability for which service connection is sought. Id. Certain diseases are deemed associated with herbicide agent exposure under current VA law; the list of those diseases includes ischemic heart disease but does not include atrial fibrillation or aortic valve stenosis. 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307, 3.309. However, a claimant is not precluded from establishing service connection with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). 1. Entitlement to service or secondary service-connection for atrial fibrillation with aortic valve stenosis, to include hormone treatments for prostate cancer is denied. The Veteran contends that his atrial fibrillation with aortic valve stenosis are related to service, to include as secondary to his service-connected disabilities, and to include hormone treatments for prostate cancer. The Veteran contended in a February 2012 statement that hormone treatments for prostate cancer included a side effect of atrial fibrillation. VA treatment records do indicate hormone treatment for prostate cancer and included that the Veteran was prescribed Casodex, an anti-androgen (male hormone) during the appellate period. The question before the Board is whether the Veteran’s atrial fibrillation with aortic valve stenosis can be attributed to service, to include as proximately due to or aggravated by his service-connected disabilities, to include hormone treatments for prostate cancer. The May 1967 pre-induction physical shows no evidence of atrial fibrillation with aortic valve stenosis, and for the June 1971 separation physical the Veteran checked off shortness of breath, pain or pressure in chest, chronic cough and palpitation of pounding heart. It is unclear if this was due to his ongoing cold, at that time, or possible indication of heart issues. However, at the separation physical the Veteran said it is all related to smoking 1 pack a day for 11 years. No other treatment was sought to date. The Veteran denied other significant medical history. The March 2018 examiner stated that as for the other diagnosed heart conditions of atrial fibrillation and aortic valve stenosis, medical records note the Veteran has a long standing history of atrial fibrillation. Atrial fibrillation is not known to be caused by herbicide exposure. The examiner noted that it is not likely that the atrial fibrillation was caused by the diagnosed non-obstructive coronary artery disease (CAD). Hypertension and age can lead to atrial fibrillation. The Veteran has a history of hypertension which is at least as likely the cause of the atrial fibrillation. The diagnosed aortic valve stenosis is likely related to age or congenital factors and less likely related to service. Calcium can buildup on the valve and, with age, heart valves may accumulate deposits of calcium causing stenosis which is most common in older people. Therefore, the March 2018 examiner opined that it is less likely that the atrial fibrillation and aortic valve stenosis began during Veteran’s active service, or is otherwise related to service, including his presumed exposure to herbicide exposure during service. The examiner further stated on November 19, 2019 that the Veteran’s atrial fibrillation and aortic valve stenosis did not begin during his active service, therefore, these additional diagnoses are less likely related to his service. The examiner stated that the Veteran does have a history of hypertension. As noted above, the case was again remanded in December 2020, because the RO obtained March 2018 VA examination and two subsequent addendum opinions in November 2019 and August 2020, did not adequately addressed aggravation. In addition, in the August 2020 opinion, the examiner’s report indicates a possible link between the other service-connected heart disability and the atrial fibrillation but did not provide a non-speculative opinion on this question. The December 2020 VA examiner after a review of the Veteran’s claims file, provided opinions against service connection, to include on a secondary basis. The Board finds that this opinion, when considered with all evidence of record, provides adequate opinions on the direct and secondary questions before it, and that the opinion is supported by adequate rationale. In light of the opinions, in their totality, the Board finds that there is sufficient opinion evidence on which to proceed with adjudication of this appeal without seeking additional opinion. This opinion weighs against direct service connection, to include as due to presumed herbicide exposure, and against a finding that a service-connected disability caused or aggravated the diagnosed atrial fibrillation. The Board finds that VA has fulfilled its duty to provide all reasonable assistance in this appeal. All cited evidence has been thoroughly reviewed and considered. There has been no additional probative evidence received which provides a link/nexus between this claimed disability and the Veteran’s military service or secondary to any service connected disability, to include hormone treatments for prostate cancer. The Board finds that the preponderance of evidence weighs against the claim for direct and secondary service-connection for atrial fibrillation with aortic valve stenosis to include hormone treatment for prostate cancer. The record does not show that atrial fibrillation with aortic valve stenosis was related to service, to include as proximately due to or aggravated by service-connected disabilities to include hormone treatment for prostate cancer. Regarding evidence and contentions regarding a link to hypertension, service connection is not in effect for hypertension and, therefore, this cannot provide a basis for service connection. The December 2020 medical opinion cites to medical literature and evidence of record that is sufficient to support the medical opinion. The medical opinion considered the Veteran’s specific medical conditions and lay reports contained within his record. These opinions weigh against service connection. The December 2020 VA medical opinion cited to medical literature supporting the conclusion, and the opinion provided a detailed rationale based on the Veteran’s medical history. Consequently, the Board gives such opinions more probative weight. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008), Barr v. Nicholson, 21 Vet. App. 303 (2007), Stefl v. Nicholson, 21 Vet. App. 120 (2007), Prejean v. West, 13 Vet. App. 444 (2000). For a heart condition to be service-connected on the basis of herbicide exposure it must be an ischemic heart condition. The March 2020 Board decision granted service connection for atherosclerotic cardiovascular disease, finding it to be a type of ischemic heart disease. The present issue before the Board is whether service connection is warranted for the separately diagnosed atrial fibrillation. The record does not contain competent evidence of a link between this separate diagnosis and the presumed exposure. The December 2020 VA opinion found there was not a link between this exposure and this separate diagnosis. The Veteran believes his atrial fibrillation with aortic valve stenosis is service-connected or proximately due to or the result of/aggravated beyond its natural progression by service-connected disabilities to include hormone treatment for prostate cancer. The Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the skills or medical training to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Based on the above, the Board finds that the Veteran’s atrial fibrillation with aortic valve stenosis was not related to service, to include as proximately due to or aggravated by service-connected disabilities or hormone treatment for prostate cancer. As the evidence weighs against a finding that atrial fibrillation with aortic valve stenosis is caused by or incurred in service or, alternatively, proximately due to or aggravated by service-connected disabilities or hormone treatment for prostate cancer described above, the claim must be denied. Nathaniel J. Doan Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Ottley III 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.