BVA9501438 DOCKET NO. 93-07 205 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin THE ISSUES 1. Entitlement to service connection for coronary arteriosclerotic heart disease, secondary to service-connected post-traumatic atrial fibrillation. 2. Entitlement to service connection for an enlarged heart, secondary to service-connected post-traumatic atrial fibrillation. 3. Entitlement to an increased evaluation for post-traumatic atrial fibrillation. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Brynn K. Bloomgren, Associate Counsel INTRODUCTION The veteran had active duty from September 1967 to June 1973. This matter came before the Board of Veterans' Appeals (hereinafter the Board) on appeal from a May 1991 rating decision of the Milwaukee, Wisconsin, Regional Office (hereinafter RO) of the Department of Veterans Affairs (hereinafter VA), which denied entitlement to service connection for arteriosclerotic heart disease, secondary to post-traumatic atrial fibrillation, and for an increased evaluation for atrial fibrillation, currently rated 10 percent disabling. We note that the disability has been previously described as auricular fibrillation, notwithstanding the diagnosis of atrial fibrillation in service. By his notice of disagreement, the veteran raised the issue of entitlement to service connection for enlarged heart, secondary to post-traumatic atrial fibrillation, rated 10 percent disabling. We find that this issue is inextricably intertwined with the issue of entitlement to an increased evaluation for atrial fibrillation. Harris v. Derwinski, 1 Vet.App. 180, 183 (1991). These issues must be addressed together. REMAND The veteran contends that an increased evaluation for post- traumatic atrial fibrillation, rated 10 percent disabling, is warranted. He claims that, as a result of his injury in service, scar tissue was formed in his heart resulting in blockage and acceleration of heart disease, as well as an enlarged heart. He seeks, therefore, service-connection and compensation for these additional disabilities on a secondary basis. The record reveals that, as a result of an accident in service in January 1972 , the veteran sustained post-traumatic atrial fibrillation, which required cardioversion. Initially, the service records show that the fibrillation was thought due to blunt chest trauma, but a Medical Board in November 1972 found that diagnosis no longer correct. Accordingly, the diagnosis was changed to idiopathic atrial fibrillation. Post-service medical records show that there was left atrial enlargement noted in February 1986. Hypertension was diagnosed in March 1986. In December 1990, the veteran underwent coronary bypass surgery for triple vessel coronary arteriosclerotic disease. A history of chronic fibrillation secondary to chest contusion and hypertension was noted at that time. In March 1991, the RO requested that the record be reviewed by a Board of two cardiologists to determine whether auricular fibrillation post traumatic was a precipitating factor for the veteran's heart disease. The cardiologists did not conduct an examination of the veteran at the time, and complete service and private treatment reports were not yet associated with the claims file. The veteran submitted an August 1992 statement from John M. Knutson, M.D., who, following a review of the veteran's records, wrote: It appears clear to me that a fairly significant injury to the heart occurred which caused scarring of the heart muscle as well as the arrhythmia, atrial fibrillation. Thus, there is a strong possibility that the blood vessels themselves were also traumatized. Trama (sic) to the blood vessels would lead to the process of accelerated degeneration and plaque formation of the arteries, and thus to his coronary artery disease and subsequent bypass surgery at his young age. The veteran also submitted a statement from Terrence P. Horrigan, M.D., Chief, Cardiothoracic Surgery, Ramsey Clinic. Dr. Horrigan wrote that, in his opinion, the 10 percent disability rating assigned the veteran's service connected disorder is inadequate, and recommended reevaluation. The veteran most recently submitted a statement from Turner Camp, M.D., dated in July 1993. Dr. Camp, a VFW medical consultant, pointed out that the veteran's medical records appear to be incomplete. He also provided information from a medical text to the effect that blunt trauma may cause cardiovascular injury. The veteran's legal representative has requested additional development. After careful review of the claims file, we agree that additional development is necessary. The RO has not made a search for additional service records. Also, it has not provided the veteran with an examination of his service-connected disability since June 1978. The VA has a duty to provide the veteran with a thorough and contemporaneous examination of the claimed disability so that an evaluation will be a fully informed one. Green v. Derwinski, 1 Vet.App. 121, 124 (1991). Moreover, the records available to the Board of Cardiologists did not include the more recent medical opinions, complete service records, nor an examination of the service-connected disability. Further, we note that additional evidence has been received without waiver of VARO consideration, after the claims folder was transferred to the Board. The evidence was thereupon forwarded to the Board as required by 38 C.F.R. § 19.37(b) (1993). Any pertinent evidence submitted by the appellant and forwarded to the Board under 38 C.F.R. § 19.37(b) must be referred to the agency of original jurisdiction for review and preparation of a supplemental statement of the case unless this procedural right is waived by the appellant. 38 C.F.R. § 20.1304(c) (1993). Based on the foregoing, the case is REMANDED to the RO for the following development: 1. The RO should obtain and associate with the claims file all available service medical records. 2. The veteran should be afforded a VA cardiology examination by a Board of cardiologists, who have not previously examined him, to determine the extent and severity of his service connected disability, and to express their opinions as to the full extent of residual disability traceable thereto. The examiners should (1) consider, by review of the service records, whether the veteran, in fact, suffered chest contusion resulting in atrial fibrillation, and (2) express an opinion as to the effect of the long term atrial fibrillation disorder on the veteran's health, and the level of current residual disability. The examiners should state whether the disorder incurred in service is etiologically related to enlargement of the heart or arteriosclerotic heat disease. The clinical basis for all opinions should be discussed. The claims folder and a copy of this REMAND shall be made available to the examiners prior to examination. 3. Inasmuch as the issue of entitlement to service connection for enlargement of the heart, secondary to atrial fibrillation, is deemed to be "inextricably intertwined" with the issue of an increased evaluation for the fibrillation, the RO should take appropriate adjudicative action, and provide the appellant and representative, if any, notice of the determination and the right to appeal. If a timely notice of disagreement is filed, the appellant and representative, if any, should be furnished with a statement of the case and given time to respond thereto. Thereafter, the case should be returned to the Board, if in order. The Board intimates no opinion as to the ultimate outcome of this case. The appellant need take no action unless otherwise notified. (CONTINUED ON NEXT PAGE) JACK W. BLASINGAME 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. Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Veterans Appeals. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1993).