Citation Nr: 25005455 Decision Date: 04/23/25 Archive Date: 04/23/25 DOCKET NO. 11-06 939 DATE: April 23, 2025 ORDER Entitlement to compensation under 38 U.S.C. § 1151 for status post aortic insufficiency due to bacterial endocarditis, with bovine aortic valve replacement and possible transient congestive heart failure (claimed as heart murmur, congestive heart failure, and aortic valve replacement) is denied. FINDING OF FACT The Veteran does not have a qualifying additional disability that resulted from carelessness, negligence, lack of proper skill, error in judgment, or a similar instance of fault on the part of VA in furnishing the care or that it was an event that was not reasonably foreseeable. CONCLUSION OF LAW The criteria for compensation under 38 U.S.C. § 1151 for status post aortic insufficiency due to bacterial endocarditis, with bovine aortic valve replacement and possible transient congestive heart failure are not met. 38 U.S.C. § 1151, 5107; 38 C.F.R. §§ 3.102, 3.361. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty with the United States Navy from April 1976 to May 1984. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2009 rating decision of the Department of Veterans Affairs (VA) Regional office (RO). The Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge in October 2017. A transcript of the hearing is associated with the claims file. This matter was before the Board in July 2014, March 2017, December 2017, and October 2019, when the Board remanded the claim for additional development. In July 2020, the Board issued a decision that denied entitlement to compensation under 38 U.S.C. § 1151 for status post aortic insufficiency due to bacterial endocarditis, with bovine aortic valve replacement and possible transient congestive heart failure. The Veteran appealed the decision to the Court of Appeals for Veteran's Claims (Court). In May 2021, the Court approved a Joint Motion for Remand vacating the Board's decision and remanding the case to the Board for action consistent with the Joint Motion for Remand. The matter was again remanded by the Board for further development in August 2021, January 2022, and June 2022. In March 2023, the Board issued another decision denying entitlement to compensation under 38 U.S.C. § 1151 for status post aortic insufficiency due to bacterial endocarditis, with bovine aortic valve replacement and possible transient congestive heart failure. The Veteran again appealed the denial to the Court, and by a new Order the Court granted a December 2023 Joint Motion for Remand (Joint Motion) vacating the March 2023 Board's decision and remanding that decision for readjudication consistent with the new Joint Motion. In June 2024, the Board remanded the claim again for action consistent with the new Joint Motion. The case was remanded again for further development in February 2025. Pursuant to the December 2023 Joint Motion, the Veteran's VA treatment records dated from August 2010 to December 2016 and his Social Security records were obtained and added to the claims file in July 2024. VA also obtained a new medical opinion which the Board finds adequate to decide the claim. The Board therefore concludes that there has been substantial compliance with its prior remand. Stegall v. West, 11 Vet. App. 268 (1998). Entitlement to compensation under 38 U.S.C. § 1151 for status post aortic insufficiency due to bacterial endocarditis, with bovine aortic valve replacement and possible transient congestive heart failure. The Veteran seeks compensation under 38 U.S.C. § 1151 and asserts that he has a heart disability status post aortic valve replacement as a result of treatment at the VA between January 2007 and May 2007. The Veteran specifically attributes his heart condition to a peripherally inserted central catheter (PICC) line that was inserted on February 1, 2007 and later found to be infected with bacteria, which he asserts caused his endocarditis, severe aortic valve regurgitation with vegetation, and congestive heart failure, which necessitated aortic valve replacement surgery at the University of Arkansas Medical System (UAMS) on May 1, 2007. When a claimant incurs additional disability or death as the result of training, hospital care, medical or surgical treatment, or an examination by VA, disability compensation shall be awarded in the same manner as if such additional disability or death were service-connected. 38 U.S.C. § 1151; 38 C.F.R. § 3.358(a). To be awarded compensation under section 1151, a claimant must show that VA treatment (or other qualifying event) resulted in additional disability, and further, that the proximate cause of the additional disability was carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing the medical or surgical treatment, or that the proximate cause of the disability was an event which was not reasonably foreseeable. 38 U.S.C. § 1151; 38 C.F.R. § 3.361. See also VAOPGCPREC 40-97, 63 Fed. Reg. 31,262 (1998). To determine whether additional disability exists, the claimant's physical condition immediately prior to the beginning of the hospital care, medical or surgical treatment, or other relevant incident in which the claimed disease or injury was sustained upon which the claim is based, is compared to the claimant's condition after such treatment, examination or program has stopped. 38 C.F.R. § 3.361(b). Provided that additional disability exists, the next consideration is whether the causation requirements for a valid claim for benefits have been met, to consist of both actual and proximate causation. In order to establish actual causation, the evidence must show that the medical or surgical treatment rendered resulted in the additional disability. If it is shown merely that a claimant received medical care or treatment, and has an additional disability, that in and of itself would not demonstrate actual causation. 38 C.F.R. § 3.361(c)(1). The proximate cause of the disability claimed must be the event that directly caused it, as distinguished from a remote contributing cause. To establish that carelessness, negligence, lack of proper skill, error in judgment or other instance of fault proximately caused the additional disability, it must be shown that VA failed to exercise the degree of care expected by a reasonable treatment provider, or furnished the treatment at issue without informed consent. 38 C.F.R. § 3.361(d)(1). Proximate cause may also be established where the additional disability was an event not reasonably foreseeable, based on what a reasonable health care provider would have foreseen. The event need not be completely unforeseeable or unimaginable but must be one that a reasonable medical provider would not have considered to be an ordinary risk of the treatment provided. In determining whether an event was reasonably foreseeable, VA will consider the type of risk that a reasonable health care provider would have disclosed as part of the procedures for informed consent (in accordance with 38 C.F.R. § 17.32). 38 C.F.R. § 3.361(d)(2). In order for additional disability to be compensable, it must have been actually caused by, and not merely coincidental to, hospital care, medical or surgical treatment, or medical examination furnished by a VA employee or in a VA facility. Loving v. Nicholson, 19 Vet. App. 96, 99-100 (2005). The additional disability must have been the result of injury flowing directly from the actual provision of care, treatment, or examination furnished by VA. Id. at 101. The mere fact that a claimant is harmed by an event that occurs coincidentally with VA care, treatment, or an examination is not sufficient to establish causation. Mangham v. Shinseki, 23 Vet. App. 284, 287 (2009). The relevant issue is whether VA's direct actions caused harm. Id. at 289. In Schertz v. Shinseki, 26 Vet. App. 362 (2013), the United States Court of Appeals for Veterans Claims (Veterans Court) held that, with regard to the determination as to whether an event is reasonably foreseeable, the actual foreseeability of an event by a treating physician or other medical professional is not dispositive. Rather, the Veterans Court held that the test of foreseeability is what an objective 'reasonable health care provider' would have considered to be an ordinary risk of treatment that would be disclosed to the patient in connection with the informed consent procedures of 38 C.F.R. § 17.32. Id. at 368. If the Board finds that there is no "actual causation," it is unnecessary to address the next step of proximate causation (i.e., negligence and reasonable foreseeability). That is, if the evidence of record does not demonstrate additional disability caused by VA treatment, examination, or surgery, the analysis need not advance to the question of proximate cause, including negligence and reasonable foreseeability. Mangham v. Shinseki, 23 Vet. App. 284, 287-88 (2009); Loving v. Nicholson, 19 Vet. App. 96, 99-100 (2005). See also 38 U.S.C. § 1151(a)(1); 38 C.F.R. § 3.361(d). A January 25, 2007 VA treatment record reflects that the Veteran presented to the emergency room with complaints of neck and back pain and was admitted with a diagnosis of possible osteomyelitis. Apparently, blood cultures grew bacterial enterococcus, and antibiotic treatment was ordered, including vancomycin. See Discharge Note, April 2007 (but note that he was previously discharged to the nursing unit in February 2007). A January 25, 2007 record reflects that it was planned for him to undergo several weeks of IV therapy at the nursing home care unit (NHCU) due to his recent history of IV drug use. A February 1, 2007 record reflects that a PICC line was inserted. A February 1, 2007 consent form, signed by the Veteran, is associated with the claims file. On February 5, 2007, a transesophageal echocardiography (TEE) was performed for possible infective endocarditis (IE) which showed no vegetation but some aortic regurgitation. See Discharge Note, April 2007. The Veteran was discharged to the NHCU. See Discharge Notes, February 2007 and April 2007. Four to five weeks later, in March 2007, the Veteran experienced rigors, chills, and a fever. Blood cultures grew Acinetobacter baumannii and the PICC line was pulled due to suspicions as the source of said infection. He was then treated with antibiotics. See Discharge Note, April 2007. Due to subsequent complaints of shortness of breath, the Veteran was readmitted to the VA hospital from April 4 to 19, 2007, for cardiac testing, which revealed bacterial endocarditis, aortic valve vegetation, and severe aortic regurgitation. Aortic valve replacement surgery was postponed for two weeks for dental care. See Discharge Note, April 2007. The Veteran was admitted again on April 24, 2007 due to edema and shortness of breath, and ultimately transferred to the UAMS for aortic valve replacement surgery on May 1, 2007. The Veteran was afforded a VA examination in connection with his claim in July 2009. The examiner diagnosed status-post aortic insufficiency secondary to bacterial endocarditis with bovine aortic valve replacement in May 2007 and noted one episode of sepsis, "probably secondary to infected PICC line." The examiner found it likely that the PICC line became infected, possibly leading to the development of bacterial endocarditis, but that such a conclusion was ultimately based on speculation. He could not confirm that the PICC line was left inserted for a significant length of time. He was ultimately unable to determine from the record that there was any carelessness, negligence, lack of proper skill, or error involved in the Veteran's case but indicated that it was possible the Veteran's history of IV drug use could have caused the discitis and bacterial endocarditis. The examiner concluded that based on the evidence of record, the Veteran's management during the medical treatment in question was "standard and unremarkable" and noted that "PICC lines have a high instance of infection even with excellent care." Nevertheless, the examiner indicated that he could not determine that the events described by the Veteran were reasonably foreseeable. The examiner provided a follow-up opinion in August 2009 in which he noted the Veteran's signature on a consent form that "clearly explains that infection of the [PICC] line is a possibility." A copy of the consent form, signed by the Veteran in February 2007, has been associated with the claims file. It specifically warns that known risks of PICC access include "severe or life-threatening side effects such as infection, bleeding, shock, stroke, heart attack, and/or kidney failure." During his October 2017 hearing, the Veteran testified that VA medical personnel ignored signs and symptoms of infection until the infection had gotten so severe that he ended up requiring valve replacement surgery. He also asserted that he was told by his surgeon at the time that the VA did "something wrong" while in their care. In April 2018, in accordance with the Board's December 2017 remand instructions, the RO obtained an additional VA medical opinion concerning the nature and etiology of the Veteran's disability. The examiner concluded that the Veteran developed bacterial endocarditis with aortic valve vegetation requiring prolonged antibiotic treatment and aortic valve replacement as a result of a PICC line infection with Acinetobacter Bumanii while hospitalized between January 2007 and May 2007. The examiner echoed the July 2009 examiner's finding that the Veteran's disability was not the result of carelessness, negligence, lack of proper skill, error in judgment or similar instance of fault on the part of VA in furnishing treatment; nor did it result from the failure of VA to exercise the degree of care expected of a reasonable health care provider. The examiner also reiterated the previous examiner's conclusion that PICC lines have a high instance of infection even with excellent care and noted that treatment records demonstrated that careful instructions were given for management of the Veteran's PICC line during transfer between VA facilities. The examiner provided a detailed summary of the events in question, as documented by the available medical treatment records but determined that the events were not reasonably foreseeable. Pursuant to the Board's October 2019 remand, the RO obtained an addendum opinion in December 2019 to determine whether the events that caused the Veteran's disability were reasonably foreseeable under38C.F.R. §3.361(d)(2). The examiner indicated that the Veteran incurred bacterial endocarditis with aortic valve vegetation between January 2007 to May 2007 which required prolonged antibiotic treatment and aortic valve replacement, which was a foreseen possibility and the hopes of preventing such outcome was considered at the time of hospitalization given the prolonged course of multiple antibiotics for his enterococcal cervical osteomyelitis and extensive periodontal disease. The examiner concluded that there was no additional disability incurred as a result of treatment rendered by the VA between January 2007 to May 2007 which was proximately caused by an event not reasonably foreseeable. The parties to the May 2021 Joint Motion agreed that the Board erred in not providing an adequate statement of reasons and bases for its decision by failing to address the Veteran's contentions that VA ignored signs and symptoms of the Veteran's infection and did not properly treat him until the infection had gotten so severe that he ended up requiring aortic valve replacement surgery. Specifically, the August 2021 Board remand requested an addendum opinion and the examiner was asked to determine the following: whether the aortic valve vegetation and valve replacement incurred due to an infected PICC line and bacterial endocarditis from treatment rendered by VA staff between January 2007 to May 2007 was not reasonably foreseeable; whether failure, delay, or error in PICC line infection identification and subsequent treatment of the resulting infection and bacterial endocarditis resulted in additional disabilities of aortic valve vegetation and valve replacement; whether aortic valve vegetation and valve replacement occur in every instance of PICC line infections and bacterial endocarditis, the likelihood of additional disabilities from PICC line infections and bacterial endocarditis, or whether there was fault in VA treatment that led to more severe/serious aortic valve vegetation and valve replacement. The examiner was to comment on the degree/standard of care expected of reasonable health care providers or VA treatment of PICC line infections, bacterial endocarditis, aortic valve vegetation and valve replacement after the Veteran was transferred to North Little Rock (NLR). The examiner was also requested to discuss the Veteran's lay assertions that the VA ignored signs and symptoms of infection until the infection had gotten so severe that he ended up requiring aortic valve replacement surgery, Dr. O's statements that the right antibiotics would have killed the infection responsible for destroying the aortic heart valve, the record evidencing that the Veteran received less than the directed amount of Meropenem for treatment of his infection, and the Veteran's complaints for shortness of breath and health concerns following his transfer to NLR. A November 2021 VA opinion was obtained. The examiner determined that VA treatment was appropriate and timely, appropriate protocols were followed, and that the standard of care was met. In addition, the examiner determined it is less likely than not the claimed condition was caused by or worsened as a result of VA treatment or that an additional disability arose due to carelessness, negligence, lack of skill, or similar incidence of fault on the part of attending VA personnel or an event that could not have reasonably been foreseen by a healthcare provider and/or failure on part of the VA to timely diagnose and/or properly treat the claimed disease. In support, the examiner detailed the Veteran's medical history from the time he was initially admitted for treatment for osteomyelitis to the moment he was transferred to NLR and a PICC line was inserted to administer rounds of antibiotics which resulted in an infection of Acinetobacter baumannii. His PICC line was discontinued, and Meropenem and Daptomycin were given to treat the resulting infection and as a continuation of the original treatment for osteomyelitis. The examiner noted the Veteran's IV cocaine use and decayed teeth which were later extracted, and indicated that these factors increased risk of blood infections. Due to complaints of shortness of breath, the Veteran was given a stress test which revealed aortic regurgitation and vegetation, and he was started on antibiotics. The examiner noted it was believed that one of the two organisms that grew from previous blood cultures might have been the cause of endocarditis. The Veteran was then transferred to UAMC for surgical repair of aortic regurgitation and placement of artificial valve; informed consent was obtained and risks associated with the surgery were communicated to include infection, bleeding, perioperative MI or stroke, renal failure, hepatic failure, respiratory failure, prolonged ventilatory support, heart block, pacemaker implantation, persistent infective endocarditis and infection of new valve, and possible sepsis and death. Ultimately, the examiner concluded the Veteran's case was extremely complicated, but that management of the case and associated illnesses met the standard of care at all levels while subsequent diagnoses were timely, and management was appropriate. While the Veteran did develop complications of infections, his history of IV drug use and poor dental hygiene placed him at risk for infections which were treated appropriately. In addition, the examiner noted that due to the length of time/treatment of osteomyelitis, it was necessary to place a PICC line for delivery of antibiotics and that risks were discussed with the Veteran; an infection was recognized and the PICC line was removed but subsequent management was appropriate pursuant to recommended guidelines. A February 2022 VA addendum opinion was obtained. The examiner provided a negative opinion and ultimately concluded that it is less likely than not the claimed condition was caused by or became worse asa result of VA treatment, resulting in additional disability from carelessness, negligence, lack of skill, or similar incidence of fault on part of the attending VA personnel or additional disability resulting from an event that could not have reasonably been foreseeable by a reasonable healthcare provider and/or failure on part of VA to timely diagnose and/or properly treat the claimed disease or disability nor allowed the disease or disability to continue to progress; it is less likely than not the Veteran's aortic insufficiency due to bacterial endocarditis, with bovine aortic valve replacement and possible transient congestive heart failure was caused by or became worse as a result of VA treatment; it is less likely than not the Veteran's aortic insufficiency due to bacterial endocarditis, with bovine aortic valve replacement and possible transient congestive heart failure, resulted from carelessness, negligence, lack of skill, or similar incidence of fault on the part of the attending VA personnel; and it is less likely than not the Veteran's aortic insufficiency due to bacterial endocarditis, with bovine aortic valve replacement and possible transient congestive heart failure, resulted from failure on the part of the VA to timely diagnose and/or properly treat the claimed disease or disability nor allowed the disease or disability to continue to progress. The examiner confirmed review of the records, prior opinions, and the Veteran's lay statements but indicated that he could not find the referenced statements from Dr. O relating that the right antibiotics would have killed the infection responsible for destroying the aortic heart valve. The examiner also provided a detailed recitation of the Veteran's medical history and moments leading to his aortic valve replacement. Notably, the examiner indicated that the Veteran was initially admitted for treatment of cervical osteomyelitis/discitis in January 2007 and recommended for 8 weeks of antibiotic treatment. The examiner then explained that due to the length of treatment, a PICC line was inserted for administration of antibiotics and a consent form outlining risks for PICC lines, to include infection, was signed by the Veteran in February 2007. Additionally, the examiner noted the Veteran was transferred to VA North Little Rock for long term antibiotic treatment but could not comment on the protocol for PICC line care management for the North Little Rock facility. The examiner explicitly stated there was no evidence that VA ignored signs and/or symptoms of infection, to include shortness of breath and health concerns. The examiner noted that on February 11, 2007 the Veteran complained of shortness of breath while receiving intravenous (IV) antibiotic treatment at which time he was informed that shortness of breath was a side effect of the antibiotic treatment at VA Little Rock Hospital. The examiner then stated that the Veteran received Duoneb treatment which is typical for shortness of breath and that the Veteran reported feeling better. Additionally, the examiner noted that the Veteran was pre-medicated with Benadryl prior to administration of evening antibiotic treatment, at which time the Veteran continued to report nausea and shortness of breath with the Gentamicin infusion. The examiner highlighted a February 15, 2007 treatment record evidencing occasional shortness of breath and subsequent consultations for pulmonary function testing for assessment of shortness of breath, which was believed to be caused by anemia, history of tobacco use, aortic regurgitation, anxiety, and a side effect of Gentamicin. With regard to administration of Meropenem, the examiner reported that on February 25, 2007, the Veteran was given 1 gram every 12 hours to cover bacilli bacteremia believed to be due to a PICC line infection and that administration of Daptomycin was continued, the PICC line catheter tip eventually grew out Acinetobacter baumannii, and that a February 27, 2007 infectious disease consult recommended a 14 day administration of Meropenem for the PICC line infection and to continue Daptomycin for the original duration of treatment for cervical osteomyelitis/discitis. Additionally, antibiotic susceptibility test results for Acinetobacter baumannii pathogen documented sensitivity to multiple antibiotics including Gentamicin, Imipenem, and Cefepime. The examiner explained that the Veteran was prescribed Meropenem, which is the carbapenem drug class that included imipenem with less adverse drug reactions, and that dosing was given based on treatment of PICC line infection and renal dosing considerations due to his issues with acute renal injury that resulted in cessation of Gentamicin and Vancomycin. The examiner then indicated that a February 27, 2007 infectious disease consult made no recommendations to change the antibiotic type, dosage, or frequency of Meropenem and that repeat blood cultures following antibiotic coverage were negative for Acinetobacter baumannii. The examiner concluded that aortic valve vegetation and replacement do not occur in every instance of PICC line infections and that the Veteran had a number of other risk factors for endocarditis other than PICC line infections, including male sex, injection drug use last documented in November 2006, poor dentition or dental infection, valvular heart disease (moderate aortic insufficiency), and co-infection with cervical osteomyelitis/discitis with enterococcus bacteremia. Additionally, the examiner concluded there was no definitive evidence that endocarditis was due to the PICC line infection organism Acinetobacter. In support, the examiner reasoned an April 5, 2007 cardiothoracic consult note documents enterococcus endocarditis and an April 5, 2007 infectious disease consult documents high suspicion that one of two organisms (Acinetobacter or enterococcus) as the cause of endocarditis and that an addendum April 16, 2007 infectious disease note documents repeat blood cultures evidencing enterococcus, the original bacteria found upon admission in January 2007. The examiner pointed out that an April 18, 2007 infectious disease note opined "endocarditis is likely from enterococcus, but Acinetobacter cannot be ruled out entirely." The examiner further documented that aortic valve tissue specimen from the May 2007 surgery did not grow any pathogens, a May 2007 infectious disease note states "unsure whether aortic vegetation due to VSE (Vancomycin sensitive enterococcus) or Acinetobacter since valve tissue didn't grow," an addendum cardiothoracic note in May 2007 from Dr. A.O. documents the Veteran's history of enterococcus endocarditis with resultant severe aortic insufficiency and pulmonary hypertension, and that an assessment of "status post AVR (aortic valve replacement) secondary to enterococcus endocarditis due to IVDU (intravenous drug use) was made following the aortic valve replacement surgery. The examiner explained that infective endocarditis (IE) is associated with a broad array of complications and the likelihood of complications depend on factors including infecting pathogen, duration of illness prior to therapy, and underlying comorbidities, which can occur before, during, and after completion of therapy. Additionally, complications of IE include cardiac, neurologic, renal, musculoskeletal, pulmonary complications as well as systemic infections (including embolization, metastatic infection, and mycotic aneurysm), which can occur simultaneously. The examiner also noted that IE is considered based on pathogenesis, local spread of infection, metastatic infection, and immune mediated damage and that cardiac complications are the most common complications in IE in addition to the fact that they occur in half of patients, subsequently causing heart related failure in patients with valvular insufficiency resulting from infection induced valvular damage. Lastly, the examiner reasoned that the Veteran had evidence of local spread of infection and that bacteria grew on his aortic valve, which was evidenced by a January 2007 echocardiogram finding for moderate aortic insufficiency, but despite treatment with antibiotics for cervical osteomyelitis/discitis, providing coverage for endocarditis, the heart valves became more damaged leading to severe aortic regurgitations and heart failure ultimately requiring valve replacement, a common procedure for management of selected cases of IE. An August 2022 VA opinion was obtained. The examiner concluded there is no evidence that clearly shows that aortic insufficiency due to bacterial endocarditis became worse as a result of VA treatment nor evidence of carelessness, negligence, lack of skill, or similar incidence of fault on part of the attending VA personnel noted in pertinent records reviewed that clearly shows carelessness, negligence, or lack of skill. The examiner noted the Veteran's contentions that the PICC line was clearly red around the insertion site and the cause of his problems; however, the examiner noted there is no additional disability caused by this noted in pertinent records and the history of intravenous drug use is likely the cause of initiating infections. The examiner cited to an April 2007 treatment note from Dr. O supporting the above conclusions. The examiner further concluded that aortic valve vegetation and aortic valve replacement do not occur in every PICC line infection and bacterial endocarditis, and the likelihood of aortic valve vegetation and valve replacement increases in persons with a history of intravenous drug use as there is an introduction of bacteria with dormant infections in this population. Additionally, the examiner noted the attending physician's note showed multiple medical conditions that would contribute to valve infections requiring replacement, including history of intravenous drug use, osteomyelitis, dental caries, and other comorbidities that contributed to his complaints of shortness of breath and health concerns as noted in clinical records. The examiner indicated the Veteran was at high risk to develop endocarditis and shortness of breath. With regard to the degree/standard of care expected of reasonable health care providers in treating disabilities sustained by the Veteran, the examiner concluded the standard of care would be what a minimally trained physician would do in the case of PICC line infection and would consist of antibiotics for infections and if not improvement in the clinical site, then removal of the PICC line. The parties to the December 2023 Joint Motion agreed that the Board erred when it failed to ensure that the August 2022 VA medical opinion complied with prior remand directives. The Joint Motion determined that this opinion failed to address the Veteran's contentions that VA ignored signs and symptoms of the Veteran's infection, to include his complaints for shortness of breath and health concerns and did not properly treat him until the infection had gotten so severe that he ended up requiring aortic valve replacement surgery. They additionally noted that the August 2022 VA examiner also did not address "Dr. O.'s statements that the right antibiotics would have killed the infection responsible for destroying the aortic heart valve the record evidencing that the Veteran received less than the directed amount of Meropenem for treatment of his infection." A new VA medical opinion was obtained in September 2024 and a heart examination was conducted in October 2024, the reports are discussed below. The diagnosis was congestive heart failure with heart valve replacement. After a review of the evidence, the Board finds that the Veteran did not sustain an additional disability as a result of VA treatment from January 2007 to May 2007. The evidence in this case is clear that he initially received VA treatment for osteomyelitis that was treated with a PICC line, which was later pulled in March 2007 as believed to be the source of an infection. The Veteran was subsequently found to have endocarditis and suffered from aortic valve vegetation and regurgitation requiring aortic valve replacement surgery in May 2007. However, the medical VA opinions of record are unanimous that the care provided to the Veteran was appropriate and the resulting additional disabilities were reasonably foreseeable. Most recently, the September 2024 VA examiner opined that no additional disability resulted from carelessness, negligence, lack of skill, or similar incidence of fault on the part of the attending VA personnel. The rationale was that the record shows regular evaluations of the Veteran's clinical situation as well as routine lab and specialist follow-ups to verify that the Veteran was responding and improving overtime, which appeared to be the case until the Veteran developed a PICC line infection. With regard to the Veteran's contention that VA ignored the Veteran's signs and symptoms of infection, to include his complaints for shortness of breath and health concerns, failed to properly treat the infection, and allowed the infection to continue to progress requiring aortic valve replacement surgery, the examiner noted that the Veteran had reported shortness of breath on one occasion while at North Little Rock VA, as of February 15, 2007, which improved with medication for anxiety/sleep, based on the record. The record then confirmed that Veteran had episodes of fever and rigors from February 23, 2007, to February 25, 2007, during which time he was repeatedly evaluated by nursing as well as by medical providers on call (nurse practitioner, cardiology fellow, medical resident) through the weekend, with appropriate labs ordered, including blood and urine cultures on February 23, 2007, and medications adjusted/added in that time. PICC line infection considered likely, so line was pulled on February 25, 2007. The examiner acknowledged that the Veteran complained of shortness of breath periodically during hospital admission at North Little Rock VA, beginning February 11, 2007. However, the examiner pointed out that records from multiple healthcare providers, including nurse, nurse practitioner, and even specialist, dated from February 2007 to April 4, 2007 do not establish any pattern of persistent or progressive shortness of breath; the Veteran actually denied any symptoms on several occasions. It was noted that when Veteran did report shortness of breath, vitals were stable, and the shortness of breath generally resolved with some intervention (nebulizer on one occasion, holding IV fluids on another occasion, and treating for anxiety). The examiner therefore concluded that no single etiology or progressive disorder would have been considered likely for the Veteran based on clinical presentation alone and when the Veteran reported shortness of breath in March, chest x-ray and pulmonary function test were ordered. (PFT was normal, and chest x-ray showed pulmonary congestion and slightly enlarged heart, so IV fluids were held, resolving the shortness of breath, based on the record.) Based on the foregoing, the record does not support that the Veteran presented with any progressive shortness of breath or other indicators or ongoing cardiovascular compromise from February 2007 to April 2007 during which time, the Veteran completed the 6 weeks of IV antibiotics for cervical osteomyelitis/discitis and Enterococcus bacteremia from initial hospitalization beginning January 25, 2007 (Vancomycin and Gentamicin for 4 weeks then Daptomycin for 2 weeks). The Veteran also had PICC line infection with Acinetobacter baumannii, which was managed with input from Infectious Disease service using Meropenem in the recommended dosage range for 2 weeks after which blood cultures were negative. The examiner also noted that the records reflect the Veteran requested discharge from North Little Rock VA on more than one occasion before treatment was completed, and he left the facility without any notification to staff on at least one occasion, discontinuing his own IV while in the community. The examiner stated that while the record is not clear on exactly why the cardiovascular stress test was ordered for the Veteran on April 4, 2007, (since the providers did not document progressive shortness of breath in that time or any other signs or symptoms of heart failure or new valvular dysfunction), because the Veteran did have heart murmur dating to January 2007 with associated aortic regurgitation on the February 2007 echocardiogram, a stress test was a prudent followup step for the Veteran when the Veteran improved. The Veteran was unable to exercise for the required time of the stress test on April 4, 2007, and diastolic murmur noted to be increased relative to previous. Immediate echocardiogram then confirmed severe aortic regurgitation with vegetation identified on the aortic valve, consistent with endocarditis. VA then appropriately arranged for aortic valve replacement after the proper antibiotic course and dental evaluation. The examiner also opined that no additional disability resulted from an event that could not have reasonably been foreseen by a reasonable healthcare provider. The rationale was that given the Veteran's history of IV drug use and presentation with elevated white blood cell count, lethargy, and neck pain, and the later identified Enterococcus bacteremia, the Veteran was at high risk for endocarditis even at time of initial presentation in January 2007. This was shown by the fact that VA providers suspected endocarditis as of initial presentation in January 2007, checking echocardiograms twice without identifying endocarditis and Infectious Disease services suggested antibiotic coverage that covered for endocarditis as well. The examiner further noted that endocarditis is a known cause of valvular heart disease/valvular failure necessitating valve replacements. Therefore, though a distant concern, the possibility for endocarditis with aortic valve vegetations necessitating AV replacement would have been foreseeable as an outcome for the Veteran based on initial presentation, comorbidities, and IV drug history. With regard to the Veteran's claimed statement made by Dr. O. that the right antibiotics would have killed the infection responsible for destroying the aortic heart valve and that the record evidencing the Veteran's received less than the directed amount of Meropenem, the examiner first noted that Dr. O records do not make any assertions or determinations that VA choices in antibiotics and other care caused or contributed to the Veteran's endocarditis. Further, the examiner responded to the Veteran's assertion by explaining that appropriate antibiotic choices were made, with sensitivities confirmed and dosing adjusted as needed for type of infection and renal function. The examiner therefore concluded that it cannot reasonably be asserted, based on the evidence, that Veteran received the wrong antibiotics or the wrong dosing. The examiner also pointed out that multiple VA providers discussed the possible specific causes of the Veteran's endocarditis, with Enterococcus ultimately deemed most likely to be the source of the endocarditis, rather than the Acinetobacter baumannii which was managed using Meropenem. As such, it follows that "the infection responsible for destroying the aortic heart valve," i.e. Enterococcus, was not even treated with Meropenem, and the Veteran's argument that improper dosing of Meropenem resulted in endocarditis does not stand. In this regard, the examiner noted that Dr. O confirmed "Enterococcus endocarditis" in records dated May 2007, including the Discharge Summary after AVR surgery, and Infectious Disease records dated April 16, 2007 noted the repeat blood cultures from April 2007 again positive for Enterococcus, making it the most likely cause of the endocarditis. The examiner stated that as the aortic valve tissue did not grow any bacteria after AVR surgery, cannot confirm specific organisms in the vegetations, but the weight of the medical evidence, based on providers' assessments at point of care, supports Enterococcus, the bacteria initially present for the Veteran in January 2007, as causative for the endocarditis despite adequate IV antibiotic coverage over 6 weeks, from January 2007 to March 2007. In sum, in the absence of an additional disability caused by VA medical treatment, the matter of alleged VA negligence is not met. As noted, the medical opinions in the record do not find fault in the treatment afforded to the Veteran by the VA from January 2007 to May 2007. While the Board acknowledges that the Veteran had a long course of recovery for his post status aortic insufficiency due to bacterial endocarditis, with bovine aortic valve replacement and possible transient congestive heart failure, the fact that it occurred does not make it an act of negligence. Furthermore, regarding the matter of foreseeability or whether the Veteran provided informed consent for this treatment, the record includes the February 2007 consent form related to the PICC insertion signed by the Veteran and the VA examiners opinions that the additional disabilities were reasonably foreseeable. As such, the Board may not reject medical opinions based on its own judgment and there is no contradictory medical opinion of record. The Board has acknowledged the Veteran's sincere belief that his resulting disabilities were a result of negligence on the part of the VA and the Board is sympathetic to the Veteran in this regard. However, while lay persons are competent to provide opinions on some medical issues, here, the matter of whether the infection that resulted from the PICC placement by the VA caused or contributed to the Veteran's endocarditis, severe aortic valve regurgitation with vegetation, and congestive heart failure, which necessitated aortic valve replacement surgery is a complex medical matter that falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n. 4 (Fed. Cir. 2007) (providing that lay persons are not competent to diagnose cancer). As the Veteran is not shown to be other than a layperson without appropriate training and expertise, he is not competent to offer such a complex medical opinion. Therefore, the Veteran's contentions are not competent. The collective VA opinions, provided by medical professionals, are the most probative evidence in the present inquiry. Ultimately, as the weight of the evidence is against finding that the Veteran currently has qualifying additional disabilities that resulted from carelessness, negligence, lack of proper skill, error in judgment, or a similar instance of fault on the part of VA in furnishing the care or that it was an event that was not reasonably foreseeable, the claim must be denied. See 38 U.S.C. §§ 501, 5107(b); 38 C.F.R. §§ 3.102, 4.3, 4.7; see also Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990) L. CHU Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. J. In 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.