Citation Nr: 18160575
Decision Date: 12/27/18	Archive Date: 12/27/18

DOCKET NO. 17-08 149
DATE:	December 27, 2018
Entitlement to an aortic valve disorder (to include aortic stenosis) as secondary to a service-connected disability is remanded.
The Veteran served on active duty from February 1976 to January 1977. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2014 rating decision.
The Board finds that the January 2014 VA heart examination and corresponding February 2014 medical addendum opinion are insufficient for purposes of adjudicating this claim.
The Veteran is currently service-connected for hypertension with chronic kidney disease and hypertensive heart disease.
The Veteran claims, as set forth in more detail in his substantive appeal, that he has a heart condition (claimed as a murmur) caused by long history of hypertension which in turn contributed to his aortic valve disorder. Of note, VA treatment records indicate the existence of a murmur. The Veteran further reports that based on his own research the medical literature demonstrates a link between hypertension and aortic stenosis. In particular, he provided an article entitled “Calcific Aortic Stenosis: Another Face of Atherosclerosis” by Drs. Gian Novaro and Brian Griffin. This article indicates that hypertension has consistently been linked to the development of aortic stenosis. This makes the statement of the January 2014 examiner, who opined that there is no clear evidence that hypertension leads to aortic stenosis, problematic. Accordingly, a remand needs to fully address the Veteran’s contentions and reconcile this conflicting information. 
Moreover, the January and February 2014 VA medical opinions are lacking in an aggravation opinion. This is important because the record is suggestive of a possible significance between aortic valve disease and the Veteran’s other comorbid conditions. In particular, the January 2014 examiner stated that ventricular remodeling may not aid in valve stenosis, but did not provide a clear aggravation opinion. The February 2014 VA medical examiner did not provide an aggravation opinion, but rather seemed to suggest that left ventricular hypertrophy and aortic stenosis are unrelated. Importantly, an opinion to the effect that one disability is not caused by, a result of, or secondary to another disability does not answer the question of aggravation. El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013); see also Barr v. Nicholson, 21 Vet. App. 303 (2007) (once VA undertakes an examination, it is obligated to ensure that the examination is adequate). Accordingly, a remand is necessary for a medical opinion to be obtained that addresses the issue of whether the Veteran’s aortic valve disease was aggravated by his service-connected hypertension with chronic kidney disease or hypertensive heart disease. 
The matter is REMANDED for the following action:
Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any aortic valve disorder, to include aortic stenosis. The examiner must opine whether it is at least as likely as not (1) proximately due to any service-connected 
disability, or (2) aggravated beyond its natural progression by any service-connected disability.
The examiner must address the Veteran’s contention that his hypertension caused a heart murmur or other cardiac condition leading to a valve replacement. 
Additionally, the examiner should address the medical article provided by the Veteran (“Calcific Aortic Stenosis: Another Face of Atherosclerosis” by Drs. Gian Novaro and Brian Griffin), which indicates a link between hypertension and aortic stenosis.
The examiner must provide a complete rationale on which his/her opinion is based, and must include a discussion of the medical principles as applied to the medical evidence and facts used in establishing his/her opinion.
The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a conclusion as it is to find against it.
If the examiner finds that he/she cannot provide an 
opinion without resorting to speculation, he/she should explain the inability to provide an opinion.
Shamil Patel
Acting Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	A. Dellarco, Associate Counsel 

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