Citation Nr: 22014976 Decision Date: 03/15/22 Archive Date: 03/15/22 DOCKET NO. 18-43 339 DATE: March 15, 2022 ORDER Entitlement to service connection for valvular heart disease, as secondary to service-connected coronary artery disease, is granted. Entitlement to service connection for heart valve replacement with painful scar, as secondary to service-connected valvular heart disease, is granted. REMANDED Entitlement to service connection for a heart disorder, separate and apart from coronary artery disease, valvular heart disease, and heart valve replacement, to include as due to herbicide exposure or as secondary to a service-connected heart disorder, is remanded. FINDINGS OF FACT 1. The Veteran's valvular heart disease is aggravated by his service-connected coronary artery disease. 2. The Veteran's heart valve replacement with painful scar was caused by his service-connected valvular heart disease. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for valvular heart disease and heart valve replacement, as secondary to service-connected coronary artery disease, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for entitlement to service connection for heart valve replacement with painful scar, as secondary to service-connected valvular heart disease, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1965 to March 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2016 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In August 2020, the Veteran and his wife testified at a video-conference hearing before the undersigned Veterans Law Judge (VLJ). A transcript of that hearing has been associated with the claims file. In August 2021, the Board remanded this matter for further development. That development having been completed, this matter has returned to the Board for further appellate review. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent medical or lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Service connection may also be granted on a secondary basis for a disability which is proximately due to, or the result of, a service connected disability. 38 C.F.R. § 3.310. 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 (i.e., underwent any incremental increase in disability, regardless of its permanence) by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Of note, concerning aggravation, the term "incremental increase in disability" means additional impairment of earning capacity. Objective measurement, or numerical quantification, is not required to ascertain an increase in disability. The August 2021 Board remand, in pertinent part, directed the RO to obtain an etiological opinion for the Veteran's current heart disorders, separate from his coronary artery disease. The Board specifically requested an opinion addressing whether any of the Veteran's heart disorders were secondary to his service-connected coronary artery disease. VA medical treatment record reflects the Veteran's mitral valve replacement is related to his service-connected coronary artery disease. See January 2018 Primary Care Note (reflecting coronary artery disease status post mitral valve replacement). A November 2021 VA examination report reflected the Veteran had current diagnoses of valvular heart disease and heart valve replacement. The examiner stated the Veteran's valvular heart disease was of unknown origin, and his heart valve replacement was due to his valvular heart disease. See November 2021 Heart Conditions Disability Benefits Questionnaire (DBQ). A separate examination report reflected the Veteran's heart valve replacement manifested in one painful scar. See November 2021 Scars/Disfigurement DBQ. The November 2021 VA examiner opined that he was unable to determine a baseline level of severity for the Veteran's valvular heart disease, as the medical evidence of record was insufficient to make this determination. The examiner then stated there was not enough evidence to determine how the Veteran's coronary artery disease has worsened his valvular heart disease beyond its natural progression. See November 2021 Medical Opinion DBQ. Based on the evidence of record, the Veteran's claim of entitlement to service connection for valvular heart disease is granted as secondary to his service-connected coronary artery disease. In this regard, although the November 2021 examiner could not determine how much the Veteran's service-connected coronary artery disease aggravated his valvular heart disease, the Board notes that this implicitly finds that the Veteran's coronary artery disease did in fact aggravate his valvular heart disease. The Board finds that, at the very least, the evidence for and against the claims is in relative equipoise. When the evidence for and against a claim is in relative equipoise, by law, the Board must resolve all reasonable doubt in favor of the Veteran. See 38 U.S.C. §§ 1154(b); 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Therefore, the benefit of the doubt must be resolved in favor of the Veteran and the Board finds that the criteria for entitlement to service connection for valvular heart disease, as secondary to service-connected coronary artery disease, have been satisfied. Accordingly, entitlement to service connection for valvular heart disease is granted. As the Veteran is now service-connected for valvular heart disease, the Board also finds the criteria for service connection for heart valve replacement with painful scar have also been met. In this regard, the November 2021 examination report clearly states that the Veteran's heart valve replacement was caused by his valvular heart disease. Accordingly, entitlement to service connection for heart valve replacement with painful scar is granted. REASONS FOR REMAND 1. Entitlement to service connection for a heart disorder, separate and apart from coronary artery disease, valvular heart disease, and heart valve replacement, to include as due to herbicide exposure or as secondary to a service-connected heart disorder, is remanded. As stated above, the Board previously remanded this matter to obtain opinions addressing all of the Veteran's current heart disorders, separate and apart from coronary artery disease. Although the November 2021 VA examiner identified and addressed the Veteran's now service-connected valvular heart disease and heart valve replacement, the opinion did not address the Veteran's atrial fibrillation or pulmonary hypertension. See September 2016 Heart Conditions DBQ. The Board notes that these diagnoses are considered current for VA compensation purposes. See McClain v. Nicholson, 21 Vet. App. 319 (2007) (noting that the requirement of a current disability is satisfied when the claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim). Where VA provides an examination or obtains an opinion, it must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). Accordingly, this matter is remanded to obtain an adequate medical opinion, as set forth below. Finally, as this matter is being remanded, the Veteran's updated VA treatment records should be obtained. The matters are REMANDED for the following action: 1. Make arrangements to obtain the Veteran's updated VA treatment records, dated from December 2021, forward. 2. Thereafter, arrange for an appropriate medical professional to provide an opinion. The Veteran should not be scheduled for a VA examination(s) (or telehealth interviews, reviews of the record, etc., if an in-person examination(s) is not feasible) to address the nature and etiologies of his heart conditions unless deemed necessary by the VA medical opinion provider. The entire claims file, to include a copy of this REMAND, must be reviewed by the examiner in conjunction with the opinion. The examiner should confirm in the examination report that he or she has reviewed the folder in conjunction with the opinion. After reviewing the file, the examiner must respond to the following: a) Identify, by diagnosis, each heart disorder found to be present (other than coronary artery disease, valvular heart disease, and heart valve replacement), including atrial fibrillation and pulmonary hypertension. The examiner is advised that for VA compensation purposes a current diagnosis includes any diagnosis since the claim was filed. In this case, the claim was filed in June 2016, and all heart diagnoses since then must be considered, even if they later resolve during the appeal period and are unable to be confirmed by the examiner. This includes diagnoses of atrial fibrillation and pulmonary hypertension. b) For each current disability identified, opine whether it is at least as likely as not (50 percent or greater probability) that the heart disorder was caused by the Veteran's in-service exposure to herbicides. The clinician is advised that the sole basis of a negative opinion cannot be that the identified disorders are not on the list of diseases subject to presumptive service connection based on exposure to herbicide agents. c) If the Veteran's disorder was not found to be related to his in-service herbicide exposure, the examiner should opine as to whether it is at least as likely as not (50 percent or greater probability) that it was (1) caused by, or (2) aggravated by, his service-connected coronary artery disease, valvular heart disease, and/or heart valve replacement. The examiner must provide a complete rationale for all opinions provided. P.M. DILORENZO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. M. Stedman, 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.