Decision Date: 10/31/95				Archive Date: 
10/31/95 
DOCKET NO.  93-10 665	)	DATE 
	) 
	) 
 
On appeal from the 
Department of Veterans Affairs (VA) Regional Office (RO) in 
Newark, New Jersey 
 
 
THE ISSUE 
 
Entitlement to service connection for postoperative 
residuals of coarctation of the aorta.   
 
 
REPRESENTATION 
 
Appellant represented by:	Veterans of Foreign Wars of 
the United States 
 
 
WITNESS AT HEARING ON APPEAL 
 
Appellant 
 
 
ATTORNEY FOR THE BOARD 
 
M. F. Halsey, Counsel 
INTRODUCTION 
 
The veteran served on active duty from December 1954 to 
December 1956. 
 
This matter comes to the Board of Veterans' Appeals (Board) 
on appeal from rating actions taken in April and July 1991 
that denied an application to reopen a claim of service 
connection for coarctation of the aorta.  (A claim of 
service connection was initially denied in February 1957.  
The veteran was notified of the adverse action in 
correspondence dated February 26, 1957, but did not appeal.)   
 
Pursuant to 38 U.S.C.A. § 5108 (West 1991), a previously and 
finally disallowed claim, such as the veteran's, may be 
reopened only when new and material evidence is presented or 
secured with respect to that claim.  See Jones v. Derwinski, 
1 Vet.App. 210, 215 (1991); Colvin v. Derwinski, 1 Vet.App. 
171, 174 (1991).  The RO's determinations of April and July 
1991 that new and material evidence had not been presented 
are the actions from which the veteran appealed.  However, 
following receipt of an October 1992 letter from a physician 
employed by the veteran's representative, Turner Camp, M.D., 
the RO determined that new and material evidence sufficient 
to reopen the claim had been presented.  Nevertheless, the 
RO found that a grant of service connection was not 
warranted.  Thereafter, in January 1995, the Board remanded 
the case for additional development. 
 
Received pursuant to the Board's remand, a VA examination 
report dated in March 1995 includes a medical opinion that 
the physical stress experienced by the veteran during basic 
military training precipitated a worsening of his congenital 
anomaly:  coarctation of the aorta.  This sort of evidence, 
as well as Dr. Camp's October 1992 opinion that a cardiac 
abnormality may not have been present when the veteran 
entered military service, is new and material evidence, 
raising a reasonable possibility of changing the 1957 
outcome.  Therefore, the Board finds, as did the RO, that 
the claim of service connection has been reopened.  This 
leads to the need to consider all the evidence of record on 
a de novo basis.  See Manio v. Derwinski, 1 Vet.App. 140 
(1991).  The decision that follows does so.   
 
 
CONTENTIONS OF APPELLANT ON APPEAL 
 
The veteran contends that coarctation of the aorta was 
discovered while he was on active military duty and should 
consequently be service connected.  In support of his claim, 
he points to an October 1992 medical opinion that suggests 
that the veteran may not have had this defect when he 
entered military service.  Argument has also been made that 
a March 1995 VA examination report, and opinions contained 
therein, support his claim of service connection.  He 
asserts that these medical opinions and the medical 
complications of coarctation of the aorta, including 
surgery, as documented in his service medical records lead 
to a conclusion that coarctation of the aorta either began 
during service or was aggravated thereby.   
 
 
DECISION OF THE BOARD 
 
The Board, in accordance with the provisions of 38 U.S.C.A. 
§ 7104 (West 1991), has reviewed and considered all the 
evidence and material of record in the veteran's claims 
file.  Based on its review of the relevant evidence in this 
matter, and for the following reasons and bases, it is the 
decision of the Board that the preponderance of the evidence 
is in favor of a claim of service connection for 
postoperative residuals of coarctation of the aorta.   
 
 
FINDINGS OF FACT 
 
1.  Coarctation of the aorta is a congenital disorder which 
pre-existed the veteran's period of military service.   
 
2.  The clinical condition of the veteran's coarctation of 
the aorta worsened beyond its naturally expected course 
during military service.   
 
3.  Ameliorative surgery was undertaken during service; the 
veteran experiences residual disability as a result.   
 
 
CONCLUSION OF LAW 
 
The veteran experiences postoperative residuals of 
coarctation of the aorta that was aggravated by military 
service.  38 U.S.C.A. §§ 1110, 1111, 1131, 5107 (West 1991); 
38 C.F.R. §§ 3.303, 3.304(b), 3.306(b)(1) (1994).   
 
 
REASONS AND BASES FOR FINDINGS AND CONCLUSION 
 
Factual Background 
 
The veteran's service medical records indicate that he was 
examined prior to his December 1954 induction.  This 
November 1954 examination report shows that his heart was 
considered normal and his blood pressure was 146/84. 
 
In December 1954, when treated for pharyngitis, the 
veteran's blood pressure was reported as 120/60.  A March 
1955 record shows that he was seen for complaints of 
persistent headaches and his blood pressure was noted as 
158/104.  A history of hypertension for two years was 
reported.  A subsequent record entry made in March 1955 
shows that his blood pressure was 164/118.  He was 
thereafter hospitalized for a complete cardiovascular 
evaluation.  His blood pressure was 200/110 and a systolic 
murmur was noted.  Coarctation of the aorta was diagnosed.   
 
During the course of the March 1955 cardiovascular 
evaluation, the veteran gave a history of having problems 
with dizziness, easy fatigability and a "washed-out" feeling 
after striking his head on a door frame approximately two 
years earlier.  He said that he had been hospitalized after 
high blood pressure was discovered by a family physician and 
that he had undergone all sorts of tests.  He reported that 
he was not given medication, but was told to take it easy.  
He had to leave school because it was aggravating his 
condition.  He also indicated that he thereafter worked as 
an automobile mechanic and got along quite well with the 
exception of frequent headaches and periods of dizziness.  
It was reported that the routine of basic military training 
had resulted in more frequent occurrences of head pain and 
periods of vomiting following arduous exercise.  Upon 
determining that coarctation of the aorta was the most 
likely diagnosis, the veteran was transferred to another 
hospital for further evaluation. 
 
After being admitted for further evaluation, an arteriogram 
confirmed the diagnosis of coarctation of the aorta, and the 
veteran underwent resection of the coarctation in May 1955.  
It was reported that his postoperative course was uneventful 
and that postoperative arterial pressure studies in brachial 
and femoral arteries were normal, whereas the pressure 
readings prior to surgery had been typical of coarctation of 
the aorta.  It was noted that the veteran was 
postoperatively asymptomatic except for mild postural 
hypotension.   
 
In August 1955, the veteran was hospitalized with complaints 
of chest pain, particularly in the area of the thoracotomy 
scar.  He also reported having occasional frontal headaches, 
something he had had for many years.  Upon examination, his 
blood pressure was 120/80.  Heart sounds were normal and 
there was no murmur.  An electrocardiogram, chest x-ray, and 
cardiac fluoroscopy were normal.  It was reported that the 
veteran was reassured that his high blood pressure had been 
cured and that the operation for the coarctation had been 
successful.  The diagnoses included intercostal neuralgia 
secondary to the thoracotomy and psychogenic headaches.   
 
December 1955 records show that the veteran complained of 
chest pain, headaches and cold feet.  He was hospitalized 
and reported having had frequent "nervous spells," 
headaches, colds, and cold/blue feet and legs all his life.  
It was noted that he had complained of much chest pain in 
his upper mid-chest since the May 1955 surgery.  His 
complaints also included dizziness on arising from a 
recumbent position and a productive cough.  His hospital 
course was described as being filled with numerous somatic 
complaints that changed from day to day and never amounted 
to anything.  The final diagnosis was a repaired coarctation 
of the aorta.   
 
A March 1956 record entry shows that the veteran complained 
of left chest pain, malaise, and low back pain.  It was 
noted that a physician had found no disease.  Thereafter, 
the veteran was referred to a psychiatric clinic.  It was 
noted that he was cleared medically from the point of view 
of having any further organic cardiovascular trouble, yet he 
had voiced various complaints.  The psychiatric examination 
report shows that he reported that he had felt better 
following the coarctation resection for a time, but that he 
currently felt the same as he had before the surgery, in 
fact, perhaps not as well as he had previously.  The 
diagnosis was possible anxiety reaction.   
 
A November 1956 examination report shows that the veteran 
had had cardiac surgery in 1955.  His blood pressure was 
120/86. 
 
At a January 1957 VA examination, the veteran complained of 
pain localized in the precordial region, chiefly after heavy 
lifting.  Blood pressures of 150/94 and 146/92 in the left 
arm, and 130/80 and 134/80 in the right arm were noted.  The 
heart was not enlarged to percussion and no definite murmur 
was heard.  A postoperative scar was noted on the lateral 
and posterior chest.   
 
The veteran was admitted to a private hospital in July 1963.  
His blood pressure was 135/90 and a systolic apical murmur 
was noted.  An electrocardiogram was within normal limits.  
The diagnoses included a repaired coarctation of the aorta, 
peripheral vascular disease and allergic dermatitis.   
 
A private hospital report dated in February 1969 shows that 
the veteran was admitted in January 1969 after developing 
severe precordial pain at work.  His blood pressure was 
150/80 and there were no murmurs or rales.  An 
electrocardiogram showed a first degree heart block and 
coronary ischemia.   
 
Private treatment notes dated from 1974 to 1977 show that 
hypertension was diagnosed as early as July 1977.  His 
history of repair of coarctation of the aorta was noted.  
Similar notes dated from 1981 to 1990 show that he was seen 
on occasion for hypertension.  A hospital summary dated in 
October 1986 show that the veteran was evaluated for chest 
pain, but that there was no evidence of myocardial 
infarction.  An upper respiratory infection and bronchitis 
were diagnosed.  His past history of hypertension and 
correction of coarctation of the aorta was noted.   
 
The veteran was hospitalized at a private hospital in August 
1990 with a history of left arm pain with numbness that 
radiated up to the left shoulder and to the left side of the 
chest, where he felt a sharp pain.  It was felt that the 
pain was probably musculoskeletal in origin.  Unstable 
angina was to be ruled out.  Serial electrocardiograms 
initially showed findings suspicious of a beginning injury 
pattern on the inferior wall, but this remained the same on 
subsequent electrocardiograms.  A chest x-ray showed chronic 
obstructive pulmonary disease with chronic lung changes.   
 
The veteran testified at a hearing held in October 1991 that 
he did not begin to have problems in service until eight to 
ten weeks following his entry onto active duty.  He 
indicated that he had been hospitalized for one week 
sometime before service, but that the problem could not be 
determined.  He also described the problems he had that led 
to his having to have surgery for coarctation of the aorta.   
 
An October 1991 letter from Domingo Ustaris, M.D., shows 
that the veteran was diagnosed as having hypertension, 
arteriosclerotic heart disease, chest pain which was 
probably angina, and status-post repair of coarctation of 
the aorta.  It was noted that there was no evidence of 
congestive heart failure.   
 
VA treatment notes dated in 1991 and 1992 show that the 
veteran had a history of hypertension and surgery for 
coarctation of the aorta.  A March 10, 1992, record entry 
shows that the veteran was seen for complaints of chest 
pain; it was specifically noted by the examiner that he 
doubted any residual of coarctation.  A March 1992 private 
hospital report also noted a history of chest pain.  The 
veteran was described as having chest pain syndrome with 
exertion over the previous six months. 
 
An April 1992 VA stress test report shows that an impression 
of fixed and reversible blood flow abnormalities in at least 
2 vessels was made. 
 
A May 1992 VA hospital summary refers to single vessel 
disease identified following cardiac catheterization.  The 
diagnoses also included hypertension secondary to status-
post coarctation of the aorta.   
 
In an October 1992 letter, Turner Camp, M.D., described the 
evidence of record, including evidence showing a scar which 
he opined was due to the inservice surgery.  He opined that 
the veteran had had a stressful time early in his period of 
military service.  Dr. Camp noted that the diagnosis of 
coarctation of the aorta was not made even though there were 
many symptoms.  It was felt that, at the time the diagnosis 
was finally made, and comment was made that the veteran 
should be discharged, there had been an increase in the 
severity of a cardiovascular abnormality.  Dr. Camp also 
expressed his belief that surgery for coarctation of the 
aorta was, at the time, experimental.  He indicated that the 
veteran had a stormy post-surgical course, with symptoms 
recurring.  He reported that the veteran was in fair shape 
after discharge from service.  He concluded his letter by 
saying that the military got involved in surgery to correct 
a defect that may not have been present at the time of the 
veteran's induction.  He opined that the veteran should be 
service connected because he was not symptom free and 
because his condition had deteriorated.   
 
A VA examiner reviewed evidence in the veteran's claims 
folder and current medical records in March 1995.  He 
concluded that the veteran had coarctation of the aorta that 
was successfully resected in May 1955.  He reported that 
coarctation of the aorta, by its nature, is a congenital 
anomaly.  He noted that evidence from the claims folder 
supported a finding that the veteran had this problem prior 
to service.  The examiner referred to the fact that the 
veteran had had dizziness, easy fatigability and headaches 
for several years before service.  He specifically referred 
to the veteran's pre-service hospitalization described in 
the veteran's service medical records.  The examiner opined 
that the veteran's symptoms were aggravated by basic 
military training and severe physical exertion which led to 
an early diagnosis of coarctation of the aorta.  He reported 
that the natural history of this condition was one of a 
slow, steady progression, and opined that the severe 
physical stress of basic training clearly precipitated a 
worsening of the veteran's clinical condition which led to 
surgery.  However, in retrospect, the examiner believed that 
exertion during service did not produce any lasting bad 
effects and that the surgery did not result in any unusual 
effects.  He referred to a cardiac catheterization performed 
about six months earlier that had shown normal ventricular 
function and normal coronary arteries as confirming his 
conclusion that the surgery had caused no unusual effects.  
He opined that the surgery was very successful, resulting in 
a great benefit to the veteran, incidentally pointing out 
that the average life expectancy of a patient with 
coarctation of the aorta was 34 years without surgery.  He 
concluded by saying that the veteran's current hypertension 
and obstructive pulmonary disease was not related to the 
surgery.   
 
Analysis 
 
A grant of service connection connotes several things, 
foremost among them is that there be some "disease" or 
"injury."  38 U.S.C.A. §§ 1110, 1131 (West 1991).  
Congenital defects have not been included within the meaning 
of "disease" or "injury."  38 C.F.R. § 3.303(c) (1993).  
Consequently, service connection may not be granted for any 
condition found to be a congenital defect.   
 
Although the provisions of Department of Veterans Affairs, 
Adjudication Procedure Manual, M21-1, Part VI, Paragraph 
7.20 (1992), indicate that coarctation of the aorta is a 
"defect" due to prenatal influence, within that same chapter 
of M21-1, at Paragraph 7.59, detailed instructions are 
provided for distinguishing between a congenital disease and 
a congenital defect, congenital disease being something for 
which service connection may be granted while congenital 
defect is something for which service connection may not be 
granted.  This is explained in greater detail in opinions of 
VA General Counsel.  See VAOPGCPREC 82-90, 55 Fed.Reg. 45711 
(1990); VAOPGCPREC 67-90, 55 Fed.Reg. 43253 (1990).  The 
term "defects" as used in 38 C.F.R. § 3.303(c) was defined 
by the General Counsel as "structural or inherent 
abnormalities or conditions which are more or less 
stationary in nature."  VAOPGCPREC 82-90.  It was determined 
that the distinction between defect and disease generally is 
that a "disease" is capable of improvement or deterioration 
whereas a "defect" is not.  Id. 
 
The March 1995 VA medical opinion supports the conclusion 
that this congenital anomaly is of a nature that is capable 
of improvement or deterioration.  In this opinion, the VA 
physician said that the severe physical stress of basic 
military training clearly precipitated a worsening of the 
veteran's clinical condition which, in turn, led to the need 
for surgery.  Consequently, the Board concludes that 
coarctation of the aorta experienced by the veteran is a 
congenital "disease" vice "defect." 
 
Having decided that coarctation of the aorta should be 
treated as a congenital "disease," at least for the purpose 
of adjudicating this veteran's claim of service connection, 
the Board next turns to the question of whether it is 
attributable to the veteran's period of military service or 
was aggravated thereby.   
 
A veteran is "considered to have been in sound condition 
when examined, accepted and enrolled for service except as 
to defects, infirmities, or disorders noted at entrance into 
service, or where clear and unmistakable (obvious or 
manifest) evidence demonstrates that an injury or disease 
existed prior thereto."  38 C.F.R. § 3.304(b) (1994).  While 
no pre-existing problem with coarctation of the aorta was 
noted at entry, it wasn't long after entry that this 
disorder was noted.  Indeed, when evaluated by the service 
department in March 1955, the veteran gave a history of pre-
service hospitalization for problems with hypertension.  
Symptoms that precipitated that hospitalization were the 
same ones that led to his inservice hospitalization and 
diagnosis.  Additionally, the March 1995 VA examiner pointed 
out that coarctation of the aorta was a congenital anomaly 
and he specifically opined that it had pre-existed service 
after looking at the records describing the veteran's pre-
service symptoms.  This opinion and the provisions of M21-1 
discussed above identify this problem as being structural 
and of congenital origin.  This provides definite support to 
the March 1995 conclusion that the coarctation pre-existed 
service.  The Board therefore finds that this evidence, in 
combination, constitutes obvious evidence sufficient to 
rebut the presumption of soundness.  While Dr. Camp's letter 
includes a statement to the effect that the condition may 
not have been present when the veteran entered service, this 
statement is only speculative as to the veteran's condition 
at entrance and is not supported by references to the facts 
of the case as was the March 1995 opinion.  It's interesting 
to note that Dr. Camp, at one point, specifically referred 
to the condition as having undergone an increase in severity 
early in the veteran's period of service, implying that the 
coarctation did indeed pre-exist service.  Additionally, his 
opinion that a defect may not have been present at entry is 
expressed too equivocally to be persuasive.  For all these 
reasons, but primarily because of the overwhelming showing 
that this condition, by its nature, and by medical opinion, 
is a congenital anomaly existing before December 1954, the 
Board finds that it pre-existed the veteran's period of 
service.  The veteran's history and the March 1995 report 
clearly support this conclusion.  Analysis of the claim does 
not stop at this point, however, because pre-existing 
conditions may also be found to have been aggravated by 
service.  38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. § 3.306 
(1994).  If so, a grant of service connection would be 
warranted.  Id.   
 
Any pre-existing disease or injury will be found to have 
been aggravated by military service "where there is an 
increase in disability during such service, unless there is 
a specific finding that the increase in disability is due to 
the natural progress of the disease."  38 C.F.R. § 3.306 
(1994).  In the veteran's case, his service records clearly 
show that he had problems for which he was hospitalized.  He 
then underwent surgery to correct the congenital condition--
coarctation of the aorta.  In this regard, the Board notes 
that, with the routine of basic training, he had experienced 
more frequent occurrences of head pain than he had 
previously, and with arduous exercise, he experienced 
periods of vomiting.  The March 1995 examiner opined that 
severe physical exertion had aggravated his symptoms.  This 
examiner reported that the stress of basic training clearly 
precipitated a worsening of the veteran's clinical condition 
which then led to the surgery.  He implied that this 
worsening was something beyond the natural course of the 
disease process which was normally a steady slow progression 
of symptoms.  This opinion stands uncontradicted in the 
record.  The Board therefore finds that, during service, the 
veteran's coarctation of the aorta underwent a worsening 
beyond the naturally expected progression of the disease 
process.   
 
It might be argued that the surgical correction of the 
coarctation was successful, even to the point that the 
veteran had little to no residual disability and as a 
result, service connection should not be granted.  This 
argument is supported by evidence showing that the 
coarctation and concomitant hypertension were "cured," and 
by statements such as was made in March 1995 that the 
surgery was very successful and was unrelated to currently 
shown hypertension and obstructive pulmonary disease.  A 
June 1955 record indicates that arterial pressure studies, 
while consistent with coarctation of the aorta before the 
surgery, had become normal after the surgery.  The veteran 
was considered asymptomatic except for mild postural 
hypotension, and his life may very well have been prolonged 
by the procedure.  However, the controlling regulatory 
provision in this regard states that the "usual effects of 
medical and surgical treatment in service, having the effect 
of ameliorating disease or other conditions incurred before 
enlistment ... will not be considered service connected 
unless the disease or injury is otherwise aggravated by 
service."  38 C.F.R. § 3.306(b)(1) (1993) (emphasis added).  
A liberal reading of this regulatory provision allows for a 
grant of service connection in instances when the disease or 
injury is aggravated by service even though it may later be 
surgically corrected during service, assuming that there is 
some postoperative residual disability.  There is evidence, 
as noted above, showing that the surgery performed in May 
1955 indeed had an ameliorating effect.  Nevertheless, as 
noted in the March 1995 opinion, the condition had been 
aggravated by military service.  A grant of service 
connection is therefore warranted. 
 
While it is not clear what, if any, of the veteran's 
currently manifested difficulties are attributable to the 
inservice surgery or original problem with coarctation, at 
the very least it appears that he does have a surgical scar, 
as noted by Dr. Camp.  Even though significant evidence 
exists, such as the March 1995 opinion, that dissociates the 
underlying coarctation and ameliorative surgery from current 
problems the veteran experiences, if any disability can be 
identified as being a postoperative residual of the 
veteran's coarctation of the aorta, a grant of service 
connection may be made.  As already noted, he has, if 
nothing else, a scar.  A determination as to  
 
 
 
 
whatever else might be attributed to the coarctation or 
inservice surgery is left to the RO to assess. 
 
 
ORDER 
 
Service connection for postoperative residuals of 
coarctation of the aorta is granted.   
 
 
 
		 
	J. E. DAY 
	Member, Board of Veterans' Appeals 
 
The Board of Veterans' Appeals Administrative Procedures 
Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, 
___ (1994), permits a proceeding instituted before the Board 
to be assigned to an individual member of the Board for a 
determination.  This proceeding has been assigned to an 
individual member of the Board. 
 
NOTICE OF APPELLATE RIGHTS:  Under 38 U.S.C.A. § 7266 (West 
1991), a decision of the Board of Veterans' Appeals granting 
less than the complete benefit, or benefits, sought on 
appeal is appealable to the United States Court of Veterans 
Appeals within 120 days from the date of mailing of notice 
of the decision, provided that a Notice of Disagreement 
concerning an issue which was before the Board was filed 
with the agency of original jurisdiction on or after 
November 18, 1988.  Veterans' Judicial Review Act, Pub. L. 
No. 100-687, § 402 (1988).  The date which appears on the 
face of this decision constitutes the date of mailing and 
the copy of this decision which you have received is your 
notice of the action taken on your appeal by the Board of 
Veterans' Appeals. 
 
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