Citation Nr: 22017765 Decision Date: 03/26/22 Archive Date: 03/26/22 DOCKET NO. 17-54 083 DATE: March 26, 2022 ORDER Entitlement to an initial ratings evaluation greater than 70 percent for major depressive disorder (claimed as anxiety and depression) is denied. Entitlement to a ratings evaluation for service-connected heart condition, to include bicuspid aortic valve replacement, in excess of 30 percent prior to March 5, 2021, and in excess of 60 percent thereafter, is denied. FINDINGS OF FACT 1. The evidence is persuasively against a finding that the severity, frequency, and duration of the Veteran's psychiatric symptoms more closely approximate total occupational and social impairment. 2. The evidence is persuasively against a finding that prior to March 5, 2021, the Veteran suffered acute congestive heart failure, or had metabolic equivalent (MET) testing showing a workload of 3-5 METs, or a ventricular dysfunction with an ejection fraction of 30 to 50 percent, as a result of bicuspid aortic valve replacement. 3. The evidence is persuasively against a finding that after March 5, 2021, the Veteran suffered acute congestive heart failure, or had MET testing showing a workload of 3 METs or less, or a ventricular dysfunction with ejection fraction of less than 30 percent, as a result of his bicuspid aortic valve replacement. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 70 percent for major depressive disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9434. 2. The criteria for a rating in excess of 30 percent for bicuspid aortic valve replacement before March 5, 2021, and a rating in excess of 60 percent thereafter have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.100, 4.104, Diagnostic Code 7016. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1977 to May 1980. This matter comes to the Board of Veterans' Appeals (Board) from two September 2016 rating decisions from the Veterans Affairs (VA) Regional Office (RO). The first granted service connection for major depressive disorder (claimed as anxiety and depression) with an evaluation of 30 percent. The second granted service connection for heart condition, to include bicuspid aortic valve status post valve replacement, with an evaluation of 10 percent. Both evaluations were made effective April 2016. In April 2021, a Decision Review Officer increased the rating evaluation for major depressive disorder to 70 percent effective April 2016, and increased the rating for heart condition, to include aortic valve insufficiency, status post valve replacement, from 30 percent to 60 percent, effective March 5, 2021. As the increased ratings constitute a partial grant of the benefits sought on appeal, the issue remains on appeal and is for consideration by the Board. See AB v. Brown, 6 Vet. App. 35 (1993) (a claim for an original or an increased rating remains in controversy when less than the maximum available benefit is awarded). In April 2020, the Board notified that Veteran that his previous representative was no longer accredited to represent claimants in claims before the VA. The letter informed the Veteran that his appeal would continue unless he informed the VA otherwise, as well as informed him of the proper procedure to appoint a new accredited representative. The Veteran has not indicate that he wishes to obtain new representation in this appeal. Hence, the Board recognizes the Veteran as now proceeding pro se in this appeal. The Veteran testified at a June 2020 hearing before a Veterans Law Judge (VLJ) who is no longer available. A transcript of the hearing has been filed in the record. In a September 2021, he was informed of his right to an additional hearing before a different VLJ and indicated that if no response was received withing 30 days, the Board would proceed without a hearing. No response having been received. The Board will therefore proceed without an additional hearing. As an aside, the Board also notes that the Veteran is already in receipt of a total disability rating for individual unemployability (TDIU), effective April 14, 2016, which is the entirety of the period on appeal here. As such, the Board need not address TDIU as there is no period on appeal of the underlying increased rating claims here in which TDIU could arguably have been reasonably raised. Cf. Payne v. Wilkie, 31 Vet. App. 373, 389 (2019); Harper v. Wilkie, 20 Vet. App. 356 (2018). The Board has remanded the claim twice: in December 2020 and December 2021. Substantial compliance with the remand requests having been achieved, the Board may proceed to consider the claim. See Stegall v. West, 11 Vet. App. 268 (1998). The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Increased Rating Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282, 286 (1991); Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1995). Whether the issue is one of an initial rating or an increased rating, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. See Hart v. Mansfield, 21 Vet. App. 505, 509 (2007). The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; separate ratings may be assigned for distinct disabilities resulting from the same injury only where the symptomatology for one condition is not duplicative or overlapping with the symptomatology of the other condition. See 38 C.F.R. § 4.14; see also Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is the Board, not medical personnel, that is responsible for the assignment of the appropriate evaluation to a service-connected disability. See 38 C.F.R. § 4.2 ("It is the responsibility of the rating specialist to interpret the reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present"). That is, the assignment of a disability evaluation is a factual determination, not one that requires specialized medical expertise. Pierce v. Shinseki, 18 Vet. App. 440, 443 (2004) (assignment of rating to particular disability is question of fact subject to review under clearly erroneous standard). A medical professional serves merely to provide the necessary underlying medical information upon which the evaluation of the level of impairment caused by a disability will be made. See 38 C.F.R. § 4.1 (providing that "accurate and fully descriptive medical examinations are required, with emphasis upon the limitation of activity imposed by the disabling condition"). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of his symptoms. Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a veteran is competent to report on that of which he or she has personal knowledge). Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. The percentage ratings in the Rating Schedule represent the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The percentage ratings are generally adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the disability. Id. Diagnostic Codes (DCs) are assigned by the rating officials to individual disabilities. DCs provide rating criteria specific to a particular disability. If two DCs are applicable to the same disability, the DC that allows for the higher disability rating applies. See 38 C.F.R. § 4.7. When a question arises as to which of two ratings apply under a particular DC, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. See id. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of a veteran. 38 C.F.R. § 4.3. The Rating Schedule recognizes that a single disability may result from more than one distinct injury or disease; however, rating the same disability or its manifestation(s) under different DCs - a practice known as pyramiding - is prohibited. See 38 C.F.R. § 4.14. 1. Entitlement to an initial ratings evaluation greater than 70 percent for major depressive disorder is denied. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). A 70 percent rating for mental disorders is assigned for occupational and social impairment with deficiencies in most areas, such as work, school, family relations, think, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name. Turning to the record, a psychological examination in April 2016 by a private physician assessed the Veteran as suffering depression and "anxious distress." At a September 2016 VA mental disorders examination, the Veteran reported having a depressed mood and mild concentration and sleep problems, all associated with depressive disorder. He further indicated that he suffered shaking; panic symptoms; dizziness following mild hyperventilation; and worries about financial, personal, and occupational relationships coupled with a subjective anxious mood. Though he had coped with depression for decades after his separation from the military, the added anxiety increased his impairment. He was alert and cooperative throughout the examination; was orientated as to person, time, and place; and his thought were found to be processes linear, logical, and goal directed. His affect was congruent to his mood state. He expressed no suicidal or homicidal ideation, plan, or intent, and there were no indications of delusions, hallucinations, or other signs of psychosis. He was deemed capable of handling his own affairs. He showed signs and symptoms of post-traumatic stress disorder, but the examiner could not identify a stressor. The examiner concluded that the Veteran suffered a major depressive disorder, recurrent, moderate, with an unspecified anxiety disorder. In a September 2016 addendum, he observed that while the Veteran's major depressive disorder may be associated with his military service, his anxiety disorder could not. He opined that the Veteran's depression and irritability due to his condition might cause mild occupational impairment. During an evaluation by a private psychologist in November 2016, the Veteran revealed that he rarely socialized due to his anxiety and that although he managed his own finances, he forgot to pay bills on a monthly basis. The examiner described his mood as depressed, but he was alert, oriented, and cooperative, though his affect was flattened. He displayed no delusions or hallucinations, and denied any current suicidal or homicidal ideation, intent, or plans. The private examiner found his symptoms included sadness, pessimism, feelings of failure and guilt, crying, agitation, loss of interest, inability to relax, difficulty breathing, difficulty concentrating, sleep changes, and fatigue. The psychologist confirmed the diagnoses of major depressive disorder, though rated it severe, with anxious distress. At a mental health treatment check-in that same November, the Veteran reported that he had recently felt depressed and hopeless most days, had problems with concentrating. He admitted to having passing suicidal ideations and that he had attempted suicide several years earlier. At a check-in in February 2017 he revealed "zero energy and motivation" to anything. His affect was appropriate, however, his speech was normal, attention and concentration intact, his thought content logical, goal oriented, and his judgement good. He denied suicidal or homicidal ideations. A check-in the following month, in March 2017, his mood was about the same mild to moderate depression with affect appropriate; speech normal; attention intact; though content logical and goal-directed; judgment good. He denied suicidal or homicidal ideation. Several weeks later, after a change in medication, he reported a deepening of his depression and the appearance of frequent, chronic suicidal thoughts. The dosage of his new medication was reduced. A week later, he reported that after the decrease in medication his suicidal thoughts had subsided, though he was still depressed. His affect remained appropriate; speech normal; thought content logical; judgment and impulse control good; and he denied suicidal or homicidal thoughts. Three months later, in June 2017, he appeared alert and oriented; his speech regular and normal tone; and his affect full range and congruent with thoughts that were linear and logical Although he admitted being depressed, he denied suicidal or homicidal ideation, hallucinations, delusions, and paranoia. He complained, however, of suffering "bothersome" nightmares that awakened him four or five times a week. In July 2017, the Veteran reported that his depression was getting worse. The mental status examination noted depressed affect, normal speech, intact attention and concentration, linear thought content, good judgement, and good insight. He denied suicidal and homicidal ideation and claimed that the last he had thought of suicide had been "a couple of months ago." A month later, there appeared to be no change in his mental status. He continued to deny suicidal or homicidal ideation, delusions, paranomia and his affect was full. He reported suffering a panic attack in October 2017 and stated that he tended to stary home because he was concerned how he would not function in public given his medical problems. Mental health status examinations in January, March, and April 2018 all revealed the Veteran to be oriented to time, place, and person, experiencing no difficulty with attention, concentration, or memory. His thought process was linear and goal-directed; judgment and insight appeared intact; and he reported no hallucinations, delusions, or symptoms of psychosis. He denied suicidal or homicidal ideation, plan, or intent. In January 2019 he stated that he was feeling better and declared that he was not depressed and believed his anxiety manageable. He denied thoughts of suicide or homicide. The examiner determined that he presented alert and oriented to person, time, and place; his was speech regular and normal tone; his mood "okay," and affect full ranged and congruent. His thoughts were linear, logical, and goal-directed; denied hallucinations, delusions, paranoia and his insight and judgment were good. His impulse control, however, was rated merely adequate A mental status examination in January 2020 showed him to be alert and oriented to time, place, and person. His speech was regular and normal in tone and volume; mood "okay" and affect full ranged and congruent; his thoughts linear and logical. He denied suicidal and homicidal ideations, hallucinations, delusions, and paranoia. During check-in six months later in June 2020 he again denied suicidal and homicidal ideations, hallucinations, delusions, and paranoia. A VA examination in February 2021 noted that while the Veteran had made suicide attempts a reference to a suicide attempt in 2004 after the Veteran's son had committed suicide - he "convincingly" denied current suicidal ideation. The examiner noted a depressed mood, anxiety, panic attacks, chronic sleep impairment, flattened affect, impaired judgment, impaired abstract thinking, and disturbances of motivation and mood. He further noted difficulty in establishing and maintaining effective work and social relationship; difficulty adapting to stressful circumstances, including work or work like setting; an inability to establish and maintain effective relationships; suicidal ideation; impaired impulse control, such as unprovoked irritability with periods of silence; neglect of personal appearance and hygiene; and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. The examiner determined that the Veteran was capable of managing his financial affairs, but concluded that his level of impairment was that of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and or mood. A mental status examination in April 2021 showed little change from the last several status checks: the Veteran was alert to time, place and person. His speech rate regular and normal tone and volume. His mood was "regular"; thoughts linear, logical, and goal-directed; and he denied suicidal and homicidal ideation. His insight and judgment good but his impulse control only adequate. In October 2021 he was admitted to the hospital after a suicide attempt. He was seen by a VA examiner the following month. The examiner found that the Veteran had both passive and active suicidal ideation during the review period and had been hospitalized the previous month for week after an attempt. The examiner noted a depressed mood, anxiety, impaired judgment, impaired abstract thinking, and disturbances of motivation and mood. He further observed difficulty in establishing and maintaining effective work and social relationship; difficulty adapting to stressful circumstances, including work or work like setting; an inability to establish and maintain effective relationships; suicidal ideation; obsessional rituals which interfere with routine relationships; neglect of personal appearance and hygiene; and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. He concluded that the Veteran's level of occupational or social was "total occupational and social impairment." By early December 2021 the Veteran reported feeling "good" and "adamantly" denied suicidal thoughts. He was neat and well-groomed, polite and cooperative. He was oriented to person, place, time, and situation and his thought process was linear, logical, goal directed and focused. Judgment and insight were intact, affect congruent. By January 2022, he reported that "things had steadily improved for him" and stated that he had "little to no feelings of worthlessness." He denied suicidal ideations over the past few weeks. He was assessed as a low risk for suicide. After a review of the evidence of record, the Board finds that the evidence supports a finding that the disability picture for the Veteran's psychiatric disability has more nearly approximated occupational and social impairment with deficiencies in most areas (such as work, school, family relations, judgment, thinking, or mood), consistent with the currently assigned initial 70 percent rating throughout the appeal period. In evaluating the frequency, severity, and duration of the Veteran's impairment, the Board finds that the evidence of record demonstrates that disability due to the Veteran's psychiatric disorder has approximated the schedular criteria for an initial rating of 70 percent. See Vazquez Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). The February 2021 VA examination found symptoms of: depressed mood; anxiety; panic attacks; chronic sleep impairment; flattened affect; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationship; difficulty adapting to stressful circumstances, including work or work like setting; an inability to establish and maintain effective relationships; suicidal ideation; impaired impulse control, such as unprovoked irritability with periods of silence; neglect of personal appearance and hygiene; and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. Similarly, the November 2021 examiner noted a depressed mood, anxiety, impaired judgment; impaired abstract thinking; and disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationship; difficulty adapting to stressful circumstances; including work or work like setting; an inability to establish and maintain effective relationships; suicidal ideation; obsessional rituals which interfere with routine relationships; neglect of personal appearance and hygiene; and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. The evidence does not reflect symptoms that would warrant a rating of 100 percent such as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior, persistent danger of hurting self or others; disorientation to time or place; memory loss for names of close relatives, own occupation, or own name; or any symptomatology otherwise consistent with total occupational and social impairment. The Board concludes that the Veteran's symptoms did not cause the level of impairment required for a disability rating of 100 percent. His symptoms more closely approximated the symptoms associated with a 70 percent rating and resulted in a level of impairment that most closely approximated the level of impairment associated with a 70 percent rating. In reaching this finding, the Board acknowledges the Veteran's rare reports of suicidal ideation, as well as his hospitalization in October 2021 after a suicide attempt. However, the Board does not find that these complaints and the evidence of record are reflective of a persistent danger of hurting himself or others. The Veteran's thoughts of suicide over the brief period in March 2017 appear to have been a result of a reaction to a new drug he was placed on rather than reflecting a lasting change in his mental status. The Veteran far more consistently denied suicidal thoughts over a period of three years. Furthermore, only weeks after his suicide attempt he denied continued thoughts of suicide, and was considered low risk less than 90 days later. Nonetheless, even if the Board were to find that the Veteran's symptoms were consistent with persistent danger of hurting himself, his overall symptomatology and the disability picture presented by his service-connected major depressive disorder is not reflective of, or consistent with, total occupational and social impairment as to warrant an initial 100 percent disability rating. This finding is consistent with the findings found on multiple VA examinations, pertinent VA treatment records, private assessments, as well as his own statements as to the severity and symptomatology associated with his service-connected major depressive disorder. Further, the evidentiary record dos not raise the prospect that the Veteran's disability is not and cannot be adequately rated under the rating schedule. In light of the foregoing, the Board finds that an initial rating in excess of 70 percent for the Veteran's major depressive disorder is not warranted at any period during the appeal period. 2. Entitlement to a rating in excess of 30 percent prior to March 5, 2021 and a rating in excess of 60 percent thereafter, for service-connected heart condition, to include bicuspid aortic valve replacement, is denied. The Veteran contends that he is entitled to a rating in excess of 30 percent prior to March 5, 2021 and a rating in excess of 60 percent thereafter, for service-connected heart condition, to include bicuspid aortic valve replacement. The Veteran's service-connected residuals of aortic valve replacement has been assigned staged ratings, in the form of a 30 percent rating prior to March 5, 2021, and a 60 percent rating thereafter, under 38 C.F.R. § 4.104, DC 7016. Under DC 7016, a 30 percent rating is warranted for a workload of greater than 5 METs but not greater than 7 METs causing dyspnea, fatigue, angina, dizziness, or syncope or; evidence of cardiac hypertrophy or dilatation on electrocardiogram or echocardiogram, or X-ray. A 60 percent rating is warranted for more than one episode of acute congestive heart failure in the past year, or; a workload of greater than 3 METs but not greater than 5 METs causing dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction (LVF) of 30 to 50 percent. A 100 percent rating is warranted for chronic congestive heart failure, or; workload of 3 METs or less that results in dyspnea, fatigue, angina, dizziness, or syncope, or; left LVEF of less than 30 percent. 38 C.F.R. § 4.104, DC 7016. For rating diseases of the heart, one MET (metabolic equivalent) is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. 38 C.F.R. § 4.104, Note 2. The Board finds that effective prior to March 5, 2021, the criteria for a rating in excess of 30 percent for residuals of an aortic valve replacement have not been met. Review of the Veteran's records shows the Veteran underwent aortic valve replacement in April 2002 as the result of valvular heart disease diagnosed in the 1980s. He was additionally diagnosed and treated for supraventricular arrhythmia in 2012, though he continued to suffer atrial fibrillation. In April 2014 he was referred to a specialist for aortic valve disorder after hip surgery. He reported no symptoms, however. He was diagnosed with atrial fibrillations and taken off one of his medications. He suffered a second occurrence six month later, again reporting no symptoms afterwards. His medications were left unchanged, An echocardiograph in February 2015 revealed moderate left ventricle hypertrophy and a LVEF rate of 50 to 55 percent. In December 2015 he appeared at the emergency room complaining of heaviness and pressure in chest and shortness of breath, radiating pain in his left jaw, and dizziness. He reported having similar intermittent episodes recently. The incident was diagnosed as acute dyspnea, he was released and instructed to follow-up with his cardiologist, who subsequently took him off sotalol. He returned to the emergency room three weeks later in January 2016 again complaining of chest pain, dizziness, shortness of breath, headache, and altered vision. He was advised to reduce certain medication and instructed to see his cardiologist in several days. He was examined by a VA examiner in September 2016, who noted he was service-connected for aortic valve replacement in April 2002 and treatment for supraventricular arrhythmia in 2012, as well as his subsequent atrial fibrillation. The examiner also observed that the Veteran required continuous medications to control his heart condition, which included Coumadin, Carvedilol, and aspirin. The Veteran had not suffered a myocardial infarction or congestive heart failure, The examiner noted LVEF of 84 percent in an echocardiogram in March 1980. The Veteran's heart rate was regular at 68 beats per minute (bpm), though the heart sound was abnormal due to the valve replacement. His blood pressure was 135/90. The examiner conducted an interview-based METs test and determined the METs level to be greater than 7 10 METs, a level found to be consistent with activities such as climbing stairs quickly, moderate cycling, sawing wood, or jogging. The examiner did not conduct an exercise stress test. He concluded that the Veteran's condition of supraventricular arrhythmia, vulvar heart disease post heart valve replacement was at least as likely as not incurred in service. An echocardiogram in November 2016 showed his left ventricle normal in size, with a LVEF estimate of 55 60 percent. His heart rate was 65 bpm; blood pressure 158/92. Another note in February 2020 referred to an echocardiogram in August 2019 that showed a LVEF estimate of 50 55 percent. In April 2020 the Veteran went to the emergency room complaining of shortness of breath with chest pressure over the past month, though he denied chest pains or other symptoms of cardiac arrest. The symptoms were determined to be associated with his atrial fibrillation, aggravated by his history of anxiety, and he was released with instructions to follow up as an outpatient. An echocardiogram in March 2021 showed the left ventricle was normal in size, with moderate asymmetric left ventricular hypertrophy and a LVEF estimate of 60 65 percent. It also showed evidence of cardiac dilation. A VA examination the same month, the examiner noted that the Veteran required continuous medication for his heart condition; that he had not suffered a myocardial infarction or congestive heart failure, but did suffer constant atrial fibrillation. The Veteran reported feeling shortness of breath, fatigue, and dizziness with light activity around the house such as mopping or vacuuming as well as fatigue, dizziness, and dyspnea after walking about a hundred yards at a medium pace. He was able, however, to eat, dress, and shower without fatigue, dizziness, or dyspnea. The examiner did not perform an exercise stress test, as the Veteran expressed worries that the test might exacerbate his symptoms of atrial fibrillation. Based on an interview with the Veteran, the examiner estimated that the Veteran suffered dyspnea and fatigue at a level of 3 5 METs, which was consistent with activities such as light yard work (weeding), mowing the lawn (power mower), or brisk walking. The examiner opined that the functional impact of the Veteran's heart condition was that that he experienced difficulty standing and walking for more than five minutes and was unable to do activities for more than five to ten minutes without needing to rest from shortness of breath. In late March 2021 the Veteran was sent to the emergency room from a cardiology appointment at which it was discovered to have electrocardiogram changes and ongoing chronic chest pain with syncopal symptoms. He reported that he had experienced chest pressure daily over the previous several months, lasting from 30 minutes to several hours, which had been worsening for several years. He reported dyspnea on exertion over the past several years and assessed that his functional capacity had declined significantly. An initial assessment determined that his moderate atrial fibrillation was not likely enough to explain his symptoms. Later tests detected high phosphorous levels. He was treated to lower his phosphorus level, a beta blocker was discontinued, and he was released the next day to follow up with his cariologist. A VA examination in January 2022 noted the Veteran's overall poor health, which included diagnoses of cirrhosis, chronic kidney insufficiency, diabetes, obesity, and depression. These other chronic disabilities, the examiner explained, affect the Veteran's symptoms and activity levels apart from his cardiac issues. The examiner reviewed the tests administered during his March 2021 hospitalization and noted that one of the tests included a zio patch an atrial fibrillation monitor that allows the wearer to indicate when he feels symptoms so that doctors may assess whether the wearer's responses match those of the monitor. The Veteran triggered the monitor four times for shortness of breath, light-headedness, dizziness, and chest pain, but the monitor showed that his heartrates at those times were normal. At other times, he did not indicate symptoms, but monitors suggested that he actually was undergoing cardiac and respiratory difficulty. This indicated that the Veteran's monitoring of his own symptoms did not always correlate to any objective cardiac dysfunction. The examiner speculated that the disparity might have been a side-affect of the betablocker medication he was subsequently taken off or due to another one of the Veteran's disabilities. The examiner acceded that the Veteran did indeed suffer some mild functional limitations the zio patch indicated that he suffered atrial fibrillation 100 percent of the time he was monitored but he opined that estimates of 3 5 METs to be medically reasonable as it related to the Veteran's valve replacement atrial fibrillation. Although the Veteran contends he is entitled to a rating in excess of 30 percent prior to March 5, 2021, the weight of persuasive evidence of record is against such a rating for this period. There was no showing of acute congestive heart failure, or workload of greater than 3 METS but not greater than 5 METs, or LVEF of 30 to 50 percent during the period. The Veteran's symptoms were thus closer to a 30 percent rating than a 60 percent rating. The Veteran suggest that his subjective symptoms suggest that the estimate of the METs range prior to March 5, 2021 was too high, and should have been estimated at greater than 3 METs and no greater than 5 METs. With regard to his claim for higher ratings, while the Veteran is competent to report the presence of certain symptoms, he is not competent to opine as to his specific METs levels or whether left ventricular dysfunction is present at a specific ejection fraction, as confirmation of these symptoms requires precise medical testing. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Thus, the current severity of the Veteran's residuals of aortic valve replacement must be determined based on the medical evidence of record. Moreover, as the January 2022 VA examiner pointed out, testing shows that the Veteran's subjective assessment of his symptoms do not always correlate with objective cardiac data, due either to his medications or other severe disabilities. The Board also finds that effective from March 5, 2021, the criteria for a rating in excess of 60 percent for residuals of an aortic valve replacement have not been met. The March 2021 VA examination revealed a workload of greater than 3 METs but no greater than 5 METs, which raised the prior evaluation to 60 percent. But in order for a 100 percent rating to be assigned, the competent evidence of record would need to show chronic congestive heart failure; workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope; or LVEF of less than 30 percent. 38 C.F.R. §§ 4.7, 4.104, DC 7016. However, the Veteran did not report having, nor did objective examination show, any congestive heart failure; his LVEF has never been below 50 percent; and as the January 2022 VA examiner opined, the estimate of greater than 3 METs and no greater than 5 METs constituted an accurate estimation of the Veteran's condition. Thus, effective from March 5, 2021, the competent evidence of record does not support the grant of a rating in excess of 60 percent rating for residuals of aortic valve replacement. The Board further finds that the Veteran's disability is fully capable of evaluation under the rating schedule. The Board concludes that, prior to March 5, 2021, the persuasive competent evidence supports a rating greater than 30 percent for residuals of aortic valve replacement, and effective from March 5, 2021, the competent evidence persuasively does not support a rating greater than 60 percent for residuals of aortic valve replacement. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.104, DC 7016. SHEREEN M. MARCUS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Wilkinson, Edward L. 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.