Citation Nr: 21041339 Decision Date: 07/08/21 Archive Date: 07/08/21 DOCKET NO. 18-13 974 DATE: July 8, 2021 ORDER Service connection for endocarditis, as due to in-service exposure to herbicide agents, is denied. FINDING OF FACT Endocarditis did not manifest in service and is not otherwise attributable to service. CONCLUSION OF LAW The criteria for service connection for endocarditis have not been met. 38 U.S.C. § 1101, 1110, 1113, 1131, 1137, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active duty from January 1955 to August 1978 including service in the Republic of Vietnam in 1971-72. This matter comes before the Board of Veterans' Appeals (Board) from a November 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In March 2019, April 2020, and November 2020, the Board remanded the case for additional evidentiary development. The RO substantially complied with the Board's remand directives following the most recent remand. Stegall v. West, 11 Vet. App.268 (1998). Service Connection The Veteran contends that endocarditis was incurred in, aggravated by, or otherwise attributable to service due to exposure to herbicide agents. In order to establish service connection on a direct basis, the record must contain competent evidence of: (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). In the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F. 3d 1039, 1043 (Fed. Cir. 1994). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). If the evidence is competent, the Board must then determine if the evidence is credible. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this regard, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511 (1995). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Certain chronic diseases, including endocarditis that includes all forms of valvular disease, will be presumed related to service if they were shown as chronic in service (or within a presumptive period) and there are subsequent manifestations of the same chronic diseases; or if they manifested to a compensable degree within a presumptive period following separation from service (in this case, one year); or if they were noted in service, with continuity of symptomatology since service. See 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Service connection based upon exposure to certain herbicide agents will be presumed for certain specified diseases that become manifest to a compensable degree within a specified period of time in the case of certain diseases. The diseases associated with herbicide exposure for purposes of the presumption do not include endocarditis. 38 U.S.C. § 1116 (a)(2); 38 C.F.R. § 3.309(e). Even though the evidence does not warrant presumptive service connection, the Veteran is not precluded from establishing service connection for these contended disabilities with proof of direct causation. See Combee, 34 F. 3d 1039. Evidence and Analysis A review of the Veteran's service treatment records (STRs) disclose neither complaints of, treatment for, nor an assessment of, endocarditis or other heart disorder. In the Veteran's July 1978 retirement report of medical examination, a clinician indicated normal clinical evaluations of the Veteran heart; vascular system; and abdomen and viscera. In a January 2015 lay statement, the Veteran reported that he underwent a heart procedure in December 2014 and subsequent home nursing care. The Veteran also reported that he had been prescribed a course of antibiotics. In June 2015, the Veteran submitted a copy of a law school internet printout which reports, correctly, that endocarditis is a presumptive chronic disease under the provisions of 38 C.F.R. §§ 3.307, 3.309. This printout provides no guidance as to the facts of the Veteran's medical history. (The Veteran and his representative have submitted this same document on multiple occasions throughout the pendency of this appeal.) In his December 2015 notice of disagreement (NOD), the Veteran reported that many diseases are presumptive for herbicide exposure and, as such, need not manifest within one year following separation from service. In April 2016, VA received private treatment records from S. These records show that the Veteran underwent procedures of aortic valve replacement; radical repair of the mitral valve; aortoplasty; and removal and closure of the left atrial appendage in March 2008. These records also disclose that the Veteran underwent a sternotomy; removal and debridement of an infected aortic valve; and removal and debridement of an infected mitral valve in December 2014. A physician indicated that the afore-noted valves were prosthetic. Additionally, this physician reported that the Veteran's acute left ventricular systolic valvular congestive heart failure (CHF) was related to endocarditis, likely due to infectious etiology rather than secondary to emboli. In January 2018, a VA clinician provided an opinion. This clinician interviewed the Veteran and reviewed the Veteran's claims file. The clinician indicated that the Veteran has never been diagnosed with a disorder that would meet the diagnostic criteria for ischemic heart disease. Even though a "rater" stated that coronary artery disease (CAD) is "normally" considered the same as ischemic heart disease, this would not be the concern of a clinician who deals in medical fact. Moreover, the Veteran has had no functional evidence of ischemia and has had no "events" of ischemia. The clinician opined that the Veteran's elevated troponin is consistent with endocarditis. Consequently, the findings of the catherization were non-obstructive and therefore do not meet the clinical definition of an ischemic condition. A review of VA treatment records shows that clinicians followed the Veteran's status, treatment routines, and pharmaceutical roster. Clinician specifically noted that the Veteran has undergone heart valve surgery (aortic and mitral valves). While the Veteran's on-going problems list includes aortic and mitral valve disorders, it does not include endocarditis. In January 2020, the Veteran underwent a VA heart conditions examination. A clinician reviewed the claims file; considered the Veteran's lay accounts of his medical history; and conducted an appropriate evaluation. The clinician indicated that findings, signs, and symptoms did not support a current diagnosis of endocarditis. Upon contemplation of the totality of evidence, to include findings from the instant evaluation, the clinician indicated that endocarditis was less likely than not incurred in or caused by the claimed in-service injury, or illness. As a basis for this negative nexus opinion, the clinician opined that as there was no current diagnosis of endocarditis, this disease entity could therefore not be caused by exposure to herbicide agents in service. In a May 2020 VA addendum opinion, a VA physician, upon consideration of the totality of evidence, indicated that endocarditis was less likely than not incurred in or caused by the claimed in-service injury, or illness. This clinician noted that the Veteran's STRs, to include the Veteran's 1978 retirement report of medical examination, fail to disclose ongoing acute or chronic treatment for endocarditis. Upon VA examination in January 2020, the clinician noted diagnoses of heart block, valvular heart disease, and cardiomyopathy. However, the Veteran's medical records do not reveal continuous ongoing medical treatment or aggravation of acute or chronic endocarditis from the time of discharge (retirement) to the present day. In January 2021, the Veteran underwent a VA heart conditions examination. A clinician reviewed the claims file; considered the Veteran's lay account of his medical history; and conducted an appropriate evaluation. This clinician indicated that the Veteran developed endocarditis following valve replacements (mitral and aortic) in 2014. This endocarditis treatment required the use of intervenous antibiotics. Upon contemplation of the totality of evidence, to include findings from the instant evaluation, the clinician indicated that endocarditis was less likely than not incurred in or caused by the claimed in-service injury, or illness. As a rationale for this negative nexus opinion, the clinician reported that the Veteran's retirement examination was negative for treatment or evaluation of endocarditis. The Veteran underwent valve replacement in 2008; the Veteran developed endocarditis in 2014 and underwent aortic and mitral valve replacement due to this endocarditis. Upon a subsequent transthoracic echo protocol in January 2020, there was no evidence of endocarditis. Consequently, chronicity of care for endocarditis cannot be established. In an addendum of this same month, the clinician opined that bacterial endocarditis was not present during the Veteran's military service and does not have any etiological relationship to exposure to herbicides during service. Endocarditis in not one of the diseases enumerated under the presumption for herbicide agent exposure. Hence, a nexus for endocarditis cannot be established. In an April 2021 VA addendum, a clinician, upon review of the evidence of record, also reported that endocarditis was less than not incurred in or caused by the claimed in-service injury, or illness. Upon recapitulating the January 2021 evidence-infused rationale, this clinician indicated that endocarditis is a bacterial infection that is more common in individuals with heart defects and valvular defects or replacements. Moreover, the source of this bacterial infection can be as simple as dental cleaning and may not be discernable. The Veteran no longer has an active diagnosis of endocarditis, but clearly had a "significant prior impact" due to endocarditis. Nonetheless, endocarditis is not due to Agent Orange (herbicide) exposure. It is due to an infection of the Veteran's previously surgically altered valves. This is unequivocal, established medical knowledge and practice (Cecil's or Harrison's internal medicine textbooks). Therefore, it is less likely than not that the Veteran's endocarditis, which occurred in 2014, was due to or incurred in service, including exposure to Agent Orange. There is simply no plausible rationale to connect Agent Orange exposure to the Veteran's valvular disease and/or endocarditis. Upon a review of current, widely accepted, peer-reviewed literature, it has not been established that remote Agent Orange exposure causes valvular disease. The clinician indicated that his literature review included Up to Date, a respected professional medical resource wherein one can access current literature and professional treatises, which failed to return articles establishing Agent Orange exposure as a cause of valvular disease. As noted above, the diseases associated with herbicide exposure for purposes of the presumption does not include endocarditis. See 38 U.S.C. § 1116(a)(2); 38 C.F.R. § 3.309(e). While the Veteran believes that endocarditis was caused by herbicide exposure, neither the Veteran nor his representative has submitted competent evidence to support such a theory of causation. Lay parties are competent to report what they have heard or discerned; however, the evidence of record fails to show that the Veteran or his representative have expertise in infectious diseases, cardiology, epidemiology, or environmental medicine. See 38 C.F.R. § 3.159. As such, this lay evidence does not constitute competent medical evidence. While the evidence of record shows that the Veteran had endocarditis in 2014, the weight of evidence is against finding an in-service incurrence or to a compensable level within one year of retirement from service. In the Veteran's July 1978 retirement report of medical examination, a clinician indicated normal clinical evaluations of the Veteran heart; vascular system; and abdomen and viscera. The absence of in-service incurrence weight against service connection for endocarditis on a direct basis. The Board places weight on the multiple VA medical opinions that explain the nature of the endocarditis, its onset, and its causes and that it was not caused by herbicide exposure or any other aspect of service. See Shedden, 381 F. 3d 1163. The evidence of record shows that the Veteran had endocarditis in 2014. However, the weight of evidence is against finding that endocarditis manifested to a compensable degree with one year of the Veteran's separation from active duty service. Hence, service connection cannot be established on a presumptive basis. See 38 C.F.R. §§ 3.307, 3.309. Therefore, the weight of competent and credible evidence is against the Veteran's service connection claim. As such, there are no doubts to be resolved. See 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. 49. J.W. FRANCIS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. J. Komins, 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.