Citation Nr: 21029927 Decision Date: 05/17/21 Archive Date: 05/17/21 DOCKET NO. 14-20 503 DATE: May 17, 2021 ORDER Entitlement to service connection for a circulatory condition, to include as secondary to service-connected mitral valve regurgitation and atrial fibrillation, status post mitral valvuloplasty and annuloplasty, is denied. FINDING OF FACT The Veteran does not have a current circulatory condition that originated in service or within a year of service, or that is otherwise etiologically related to active service. CONCLUSION OF LAW The criteria for service connection for a circulatory condition have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from May to September 1965 and from January to December 1991, with additional service in the Reserves. This appeal comes before the Board of Veterans' Appeals (Board) from an October 2011 rating decision from a Regional Office (RO) or Agency of Original Jurisdiction (AOJ). In September 2016 the Board remanded the Veteran's claim for development and readjudication by the AOJ. The Board again considered the Veteran's claim in May 2018. The claim was remanded yet again for a VA examination to confirm the existence of a circulatory condition and determine its etiology. The requested VA examination was performed in April 2020. The claim was returned to the Board and remanded still yet again in January 2021, this time directing the AOJ to issue a Supplemental Statement of the Case that readjudicated the Veteran's claim while considering his April 2020 VA examination. In February 2021 the AOJ issued the Veteran an SSOC continuing its denial of his condition. 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. § 1110; 38 C.F.R. § 3.303. In order to establish entitlement to service connection, there must be (1) evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) a causal connection between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury; or, for any increase in severity of a nonservice-connected disease or injury which is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of nonservice-connected condition. 38 C.F.R. § 3.310(a), (b). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Service connection may be presumed for certain chronic diseases which develop to a compensable degree within one year after discharge from service, even though there is no evidence of the disease during the period of service. That presumption is rebuttable by probative evidence to the contrary. 38 U.S.C. §§ 1101, 1137; 38 C.F.R. § 3.307, 3.309(a). The Board must determine whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either case, or whether the preponderance of the evidence is against the claim, in which case, service connection must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Circulatory Condition The Veteran seeks entitlement to service connection for a circulatory condition, to include as secondary to service-connected mitral valve regurgitation and atrial fibrillation, status post mitral valvuloplasty and annuloplasty. See April 2021 Appellate Brief (VSO IHP; Post remand Brief; Attorney Brief). Alternatively, the Veteran contends his circulatory condition was incurred coincidental to his military service. See June 2011 VA 21-4138 Statement in Support of Claim. In this regard, a review of the Veteran's DD Form 214, Certificate of Release or Discharge from Active Duty, shows he served in the Southwest Asia theater from January through December 1991. Therefore, as there is evidence that the Veteran served on active military duty in Southwest Asia, he is deemed a Persian Gulf veteran. 38 C.F.R. § 3.317. Thr Board notes that the VA Compensation Service's Medical Electronic Support System (Medical EPSS) provides that symptoms of arteriosclerosis obliterans, also known as peripheral vascular disease, may include: intermittent claudication (severe pain from inadequate blood supply in the calf muscles that occurs during walking); leg pain at rest, bruits (turbulent blood flow sounds); absent pulses; dry shiny skin; loss of hair on the legs; muscle atrophy; thick nails; cool, pale or bluish skin; and leg ulcers or gangrene. See Medical EPSS website: http://epss.vba.va.gov/mepss. Turning to the Veteran's service treatment records (STRs), an October 1964 Report of Medical History showed the Veteran denied palpitations, high or low blood pressure, and cramps in his legs. A Report of Medical Examination from the same month noted the Veteran had a normal heart and vascular system. See December 2014 STR - Medical, pages 22, 26. In September 1965, STRs show that on a Report of Medical History the Veteran denied heart palpitations, high or low blood pressure, and cramps in his legs. However, in the corresponding Report of Medical Examination, the Veteran was observed to have a mitral heart murmur. The Veteran's vascular system was evaluated as normal. See December 2014 STR - Medical, pages 19, 21. In the Veteran's STRs, on a Report of Medical History from October 1969, the Veteran denied high or low blood pressure and cramps in his legs; however, he indicated that he had heart issues. A concurrent Report of Medical examination noted the Veteran's heart had a soft flowing murmur. The Veteran's vascular system was evaluated as normal. See December 2014 STR - Medical, pages 3, 5. STRs show that, in July and August 1991, after experiencing dyspnea and symptoms of mild congestive heart failure, the Veteran underwent heart catheterization and imaging. The exam revealed evidence of severe mitral regurgitation. Veteran suffered thrombophlebitis and bacterial endocarditis as complications of the procedure and was recommended for open-heart surgery to replace his mitral valve. See August 2016 Medical Treatment Record - Government Facility, pages 1, 2, 9. Later, in September 1991, STRs indicate the Veteran underwent an open-heart mitral valvuloplasty and annuloplasty. See August 2016 Medical Treatment Record - Government Facility, pages 11-13. Later that same month, the Veteran underwent a separation exam from the military. In his Report of Medical History, he reported a history of heart trouble. The Report of Medical Examination noted no palpable thrill; however, a murmur was noted at valvular click. See October 1993 Medical Treatment Record - Government Facility, pages 17, 20. Turning to the Veteran's post-service medical history, a private medical report from June 1992 stated the Veteran was status post mitral valvuloplasty for mitral insufficiency with a residual mild mitral insufficiency murmur. This impression was reached after an examination of the Veteran's heart found a normal sinus rhythm, with a grade II sharp short systolic murmur heard at the apex and less so at the base. No diastolic murmurs, S3, or S4 sounds were heard. Additionally, there was no peripheral edema and the Veteran's peripheral pulses were good. See September 1993 Third Party Correspondence. A private medical report from late June 1992 noted that a January 1992 electrocardiogram revealed left atrial enlargement but no other pathology. See August 2016 Medical Treatment Record - Government Facility, page 19. During a VA general medical exam in February 1994 the Veteran's cardiovascular system was observed to be free from abnormal sounds, and an examination for varicose veins returned negative results. The Veteran was diagnosed with status post thrombosis of his right hand, without evidence of residuals. See February 9, 1994 VA Examination. A February 1994 VA examination for diseases of the heart revealed the Veteran had a normal carotid pulse, no jugular vein distention, and no clubbing, cyanosis, or edema of the extremities. See February 15, 1994 VA Examination. VA records show that in August 1994 the Veteran did not exhibit jugular vein distension; neither did his extremities exhibit clubbing or cyanosis. See August 2016 Medical Treatment Record - Government Facility, page 22. A private March 1997 echocardiogram revealed a dilated aortic root, aortic valve, and aorto-septal continuity; however, cardiac doppler studies revealed normal valvular flow velocities. See February 1997 Medical Treatment Record - Non-Government Facility, page 18. In April 1997 the Veteran underwent a cerebrovascular evaluation. While the study revealed evidence of plaques and stenosis, the results were hemodynamically normal. See February 1998 Medical Treatment Record - Non-Government Facility, page 4. A January 1998 letter from a private physician noted the Veteran was under treatment for mild vascular hypertension. See August 2016 Medical Treatment Record - Non-Government Facility, page 32. During a February 1998 VA examination the examiner noted no dyspnea on exertion, no angina, and no other cardiac symptoms. The heart revealed no murmur; however, an S4 was heard "without no thrill." Radiographic views of the chest revealed moderate cardiomegaly, with a cardiothoracic ratio of 17/32, and an elongated aorta. See February 1998 VA Examination A private brain study conducted in June 1999 revealed slightly decreased perfusion throughout the Veteran's cortex, possibly related to early involutionary changes related to aging and/or small vessel vascular process, such as microemboli related to the Veteran's heart condition. See September 2016 Medical Treatment Records - Furnished by SSA (1), page 4. In February 2002, VA records indicate the Veteran's heart was free from murmurs or gallops, and his extremities were free from edema and cyanosis. See May 2016 CAPRI, page 2. August and October 2002 VA primary care notes observed the Veteran did not have orthopnea, dyspnea on exertion, claudication, edema, or valvular disease. See October 2011 Medical Treatment Record - Government Facility, pages 3, 10. A November 2002 VA examination revealed normal sinus rhythm in the heart, with no murmur heard. See November 2002 VA Examination. VA records from April, August, October 2002, and July 2005 indicate the Veteran did not have orthopnea, dyspnea on exertion, claudication, edema, or valvular disease. Additionally, on those dates the Veteran's coronary arteries were absent murmurs, clicks, or gallops; his neck was absent jugular vein distension or carotid bruits; his extremities were absent clubbing, cyanosis, or edema; and his skin was not dry. See May 2016 CAPRI, pages 23, 37, 42, 56. A private November 2005 echocardiogram revealed a dilated aortic root, calcified aortic valve, normal tricuspid and pulmonic valves, and normal valvular flow velocities. The record noted the above features were those of hypertrophic non-obstructive cardiomyopathy secondary to arterial hypertension. See December 2005 Medical Treatment Record - Non-Government Facility, page 11. A December 2005 VA examination noted hypercholesterolemia on the Veteran's problem list. Additionally, the Veteran reported fatigue with exercise, stating he would walk or cycle outside for about 30 minutes and sometimes have to rest due to fatigue. However, the Veteran denied angina, dyspnea, edema, dizziness, and syncope. See December 2005 VA Examination. In June 2005 VA records show the Veteran did not have orthopnea, dyspnea on exertion, claudication, edema, or valvular disease. Additionally, his coronary arteries were free from murmurs, clicks, or gallops. See May 2016 CAPRI, page 14. A February 2011 letter from a private cardiologist noted calcified aortic valve on the Veteran's problem list. See January 2011 Third Party Correspondence. A private April 2011 consultation report noted the Veteran had varicose veins, truncal, on his calf. The Veteran was diagnosed with chronic venous disease. See July 2011 Third Party Correspondence. At an August 2011 VA examination the Veteran reported right leg numbness with a gradual onset; however, the examiner attributed this to clinical right L4/L5 radiculopathy. See August 2011 VA Examination, pages 1, 5. The Veteran underwent a VA examination for his circulatory condition in September 2011. The Veteran stated during the exam that he had no circulatory problem as such; rather, what he was claiming was the problem of numbness in his right leg. On evaluation, no circulatory condition was found. See September 2011 VA Examination, pages 19, 39. Private records from April, May, August, November 2016, March and September 2017, and December 2018 show the Veteran experienced neither color changes in his hands when cold nor cramping in his calves when walking. Neither did the Veteran show swelling in his feet or legs. His heart was observed to be free from murmurs, gallops, and rubs; his extremities did not show clubbing, cyanosis, or edema; and his peripheral pulses were normal. See September 27, 2019 Medical Treatment Record - Non-Government Facility, pages 20, 23, 26, 29, 32, 35. Private radiographs from April 2016 noted atherosclerotic changes within the Veteran's abdominal aorta. See September 27, 2019 Medical Treatment Record - Non-Government Facility, page 4. During a peripheral nerve VA examination in September 2016, the Veteran reported pain in the lower extremities; however, he denied tingling or numbness of the same. On examination the Veteran was seen to have severe intermittent pain in both extremities, with decreased sensation in his feet and toes. The Veteran was also observed to have diminished hair over his distal lower extremities. See September 2016 C&P Exam. VA records show that in September 2016 and March 2017 the Veteran's heart exhibited no discernible murmurs, rubs, or gallops, and his neck did not exhibit carotid bruits See May 2019 CAPRI, pages 219, 284. In March 2018, private treatment records indicate the Veteran reported cramping in his legs when walking. See September 27, 2019 Medical Treatment Record - Non-Government Facility, page 17. A private echocardiogram from March 2018 revealed mild aortic valve sclerosis without stenosis. See January 2019 C&P Exam (echocardiogram). During a January 2019 VA examination for heart conditions, the Veteran reported dyspnea, fatigue, and dizziness during 3-5 metabolic equivalents of task (METs) activity. The record noted that this METs level was consistent with activities such as light yard work such as weeding, mowing the lawn with a power mower, or brisk walking around 4 mph. See January 2019 C&P Exam, page 10. Private radiographs of the head from February 2019 revealed stable chronic small vessel ischemic changes and diffuse atrophy; however, no focal arterial branch occlusion or hemodynamically significant stenosis was demonstrated intracranially. Elsewhere, no hemodynamically significant stenosis or occlusion was noted within the neck vessels. Vascular calcification contributed to mild/moderate narrowing at the level of the V4 segments of bilateral vertebral arteries. See September 16, 2019 Medical Treatment Record - Non-Government Facility, page 30. In May 2019 the Veteran presented to the VA podiatry clinic seeking relief from bilateral foot pain. On examination, while the dorsalis pedalis pulse was palpable, the posterior tibial pulse was not. Additionally, lower extremity swelling was noted bilaterally. However, capillary fill time in the toes was within normal limits. See September 2019 CAPRI, page 87. VA records show that in July 2019 the Veteran reported orthopnea, dyspnea on exertion, dry cough, and shortness of breath. He stated that the shortness of breath prevented him from performing normal activities. See September 2019 CAPRI, page 49. August 2019 VA records noted a grade 2 systolic murmur in the aortic area in the Veteran's right 2nd intercoastal space. An examination of his extremities noted no edema; however, skin changes were observed in the distal part of the lower extremities which the Veteran attributed to exposure during service. The Veteran denied dyspnea. See September 2019 CAPRI, page 8. During a September 2019 visit to the VA podiatry clinic, the Veteran's pedal pulses were observed to be diminished. Swelling was noted in both lower extremities; however, capillary fill time was within normal limits to both great toes. Skin was warm to the touch, but hair growth was absent. See September 2019 CAPRI, page 26. The Veteran underwent a VA examination for artery and vein conditions in October 2019. After an in-person examination and a review of the Veteran's file, the examiner opined that it was less likely than not that the Veteran's mild varicose veins were secondary to his service-connected heart conditions. The examiner based this opinion on their review of the Veteran's folders and previous remands, as well as a lack of support in the literature of a clear nexus for the Veteran's varicose veins. Additionally, the examiner noted, the Veteran's varicose veins were noted before his heart disease progressed. The examiner concluded by noting the Veteran did not have other circulatory problems that appeared related to his service-connected heart condition. During the exam, the Veteran was confirmed to have asymptomatic varicose veins bilaterally, with beginning stasis pigmentation in both legs. See October 2019 C&P Exam, pages 1, 2. At an October 2019 peripheral nerve VA examination, the Veteran reported no sensory changes since 2016. The examiner opined that the Veteran's sensory neuropathy in both legs was more likely than not related to his service-connected fibromyalgia. See October 2019 C&P Exam. Finally, in April 2020, a medical opinion was obtained for the Veteran's claimed circulatory condition. After a review of the Veteran's file, the examiner opined the Veteran's mild varicose veins were less likely than not secondary to his service-connected heart condition. The examiner also opined that the Veteran's mild varicose veins were less likely than not aggravated by his service-connected heart condition. For both opinions, the examiner reasoned that the literature did not support a nexus for the Veteran's varicose veins, the Veteran's varicose veins were noted before his heart disease progressed, and the Veteran did not have other circulatory problems that appeared related to his service-connected heart condition. See April 2020 C&P Exam. After a review of the evidence of record, the Board finds that entitlement to service connection for a circulatory condition, to include as secondary to service-connected mitral valve regurgitation and atrial fibrillation, is not warranted. Specifically, the Board finds the preponderance of the evidence is against the following findings: that the Veteran has a current chronic circulatory condition related to the Veteran's service; and that such condition was related to the mitral open-heart surgery he underwent during service. In this regard, the Board notes that, although a private 1997 exam found the Veteran had a large aortic root, there is no evidence that this or other symptoms of vascular disease existed within a year of the Veteran leaving service in 1991. Additionally, although the Veteran's private physician diagnosed the him with chronic venous disease in April 2011, and he has shown symptoms that could be attributed to a circulatory condition such as trophic changes, cardiomegaly, plaques, claudication, and diminished pulse, both medical opinions of record found no nexus between the Veteran's claimed circulatory condition and his service-connected heart condition. Both the October 2019 and April 2020 VA medical opinions were based on a review of the Veteran's file and medical literature, and thus the Board affords them great probative weight. The Board recognizes the Veteran's lay statements regarding an in-service onset of his claimed circulatory condition. The Board also recognizes the Veteran's lay statements regarding a link between a claimed circulatory condition and his in-service cardiac event and subsequent open-heart surgery. With regard to lay evidence of a nexus, lay persons are not categorically incompetent to speak on matters of medical diagnosis or etiology. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). In this vein, the Board must consider the type of condition specifically claimed and whether it is readily amenable to lay diagnosis or probative comment on etiology. Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). The Veteran is competent to report purported symptoms such as pain, discoloration, and weakness in his limbs, or whether he has received a diagnosis from a medical professional. 38 C.F.R. § 3.159(a)(2); Barr v. Nicholson, 21 Vet. App. 303 (2007). In this regard the Board notes that, while the Veteran has claimed entitlement to service connection for a circulatory condition, during his September 2011 VA examination the Veteran admitted that he had no circulatory condition as such; rather, what he was claiming was the numbness in his right leg. The Board also notes that the October 2019 VA examiner opined that the Veteran's bilateral sensory neuropathy was more likely than not related to his fibromyalgia, and that the Veteran was granted service connection for bilateral lower extremity sensory neuropathy in February 2021, with benefits dating back to the date of the Veteran's original November 2010 claim for circulatory condition. In sum, while the Veteran has a diagnosis of varicose veins, the probative medical evidence has found that this condition is not caused or aggravated by the Veteran's service-connected heart disorder, nor was it incurred in or related to service, and there is no indication that the Veteran has any other circulatory disability which was incurred in or caused by service, or that was caused or aggravated by a service-connected disability. Accordingly, the preponderance of the probative evidence of record does not support a finding of an in-service incident or injury, nor does it support a finding that the Veteran has a current circulatory condition that is related to his service-connected heart condition. The Board therefore concludes that service connection is not warranted. The benefit-of-the-doubt doctrine is inapplicable, as the preponderance of the evidence is against the claim for service connection for a circulatory condition. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Mary E. Rude Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Slomka, Associate 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.