BVA9500359 DOCKET NO. 93-06 800 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Des Moines, Iowa THE ISSUES 1. Entitlement to service connection for heart disease for accrued benefits purposes. 2. Entitlement to service connection for the cause of the veteran's death. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Richard F. Williams, Counsel INTRODUCTION The veteran served on active duty from August 1958 to December 1961. The appellant is his widow. This case comes before the Board of Veterans' Appeals (Board) from decisions by a Department of Veterans Affairs (VA) Regional Office (RO) which denied accrued benefits, based on a claim for service connection for heart disease, and denied a claim for service connection for the cause of the veteran's death. The Board notes that the appellant has also made a claim for dependency and indemnity compensation under the provisions of 38 U.S.C.A. § 1151, and the RO has informed her that it was deferring action on that claim pending receipt of additional VA instructions. Such claim is not now before the Board and is referred to the RO for appropriate action. CONTENTIONS OF APPELLANT ON APPEAL The appellant contends that service connection is warranted for the veteran's heart disease for accrued benefits purposes. She further asserts that service connection is warranted for the cause of the veteran's death. In support of her claims, she argues, in essence, that her husband's fatal heart disease may have preexisted service but was aggravated therein. It is pointed out on her behalf that the service medical records reflect multiple episodes of heart palpitations and a rapid heart rate, and that the veteran was medically discharged from service because of a heart defect. 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 of the evidence and material of record in the veteran's claims file and medical records folders. Based on its review of the relevant evidence, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence is against the claims for service connection for heart disease for accrued benefits purposes and service connection for the cause of the veteran's death. FINDINGS OF FACT 1. During service the veteran was noted to have a congenital atrial septal defect, which is not a disability for VA compensation purposes. 2. A chronic acquired heart disease (superimposed on the congenital defect) was not present in service or for years later, and was not caused by any incident of service. 3. The veteran's death many years after service was caused by a heart disorder. 4. The only established service-connected condition was residuals of a fractured right little finger, but this played no role in the veteran's death. CONCLUSIONS OF LAW 1. Heart disease was not incurred in or aggravated by active service; the requirements for service connection for heart disease for accrued benefits purposes have not been met. 38 U.S.C.A. § 1131, 5121 (West 1991); 38 C.F.R. §§ 3.303, 3.1000 (1993). 2. A disability incurred in or aggravated by service did not cause or contribute to the veteran's death. 38 U.S.C.A. § 1310; 38 C.F.R. § 3.312. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual Background During the veteran's lifetime, service connection was only established for residuals of a fractured right little finger, rated zero percent. In July 1992, just prior to his death, the RO denied his claim for service connection for heart disease. The RO subsequently denied the appellant's request for accrued benefits, based on the claim for service connection for heart disease, and also denied her claim for service connection for the cause of the veteran's death. A certificate of death on file shows that the veteran died on July 10, 1992, in a VA medical center at the age of 53. The immediate cause of death was recorded as electromechanical disassociation of unknown etiology. Other significant conditions were reported as hypoxemia and pneumonia. An autopsy was not performed. The veteran served on active duty from August 1958 to December 1961. His enlistment examination in August 1958 was negative for any findings indicative of heart disease. The remaining service medical records show that he was admitted to the sick list in December 1961 with a diagnosis of an interatrial septal defect and transferred to a hospital with the same diagnosis shortly thereafter. It was recorded that he had been quite well until about two years prior to hospital admission when a murmur was found on a routine examination. It was further reported that, one year prior to hospital admission, the veteran noted the onset of bouts of rapid heart rhythm up to 170 per minute, which occurred approximately five times during the past year and persisted for approximately 60 to 90 minutes and subsided spontaneously. Additional history included the onset of a "butterfly" feeling in his precordium along with a dull aching sensation and a sensation of dyspnea three weeks prior to admission; these symptoms were noted both with exercise and with emotional stress, particularly with the latter. He was seen in an outpatient clinic for evaluation of those symptoms and findings consistent with an atrial septal defect were noted. He also stated that his exercise tolerance had always been normal, and review of his health record indicated no significant defects at the time of enlistment. Following hospital admission, clinical findings included a palpable heave in the left mid and lower parasternal areas, a systolic impulse noted in the second left interspace, and a Grade III, rough, crescendo type of a systolic murmur. A chest X-ray revealed heavy pulmonary vascular markings; the pulmonary arteries were prominent and the main pulmonary artery segment was enlarged. An electrocardio-gram revealed a pattern of complete right bundle-branch block. The veteran was examined by members of the Cardiology Service and the findings were felt to be consistent with an atrial septal defect of the secundum type with a significant left to right shunt. Cardiac catheterization studies were recommended but the veteran declined. It was noted that he was asymptomatic on hospital discharge. It was the opinion of the Board of Medical Survey that the atrial septal defect, of the secundum type, existed prior to enlistment and it was not aggravated by service. It was also the opinion of the Medical Board that he did not meet the minimum standards for enlistment or induction and, thereafter, he received a medical discharge because of the heart defect. Private clinical records show the veteran was hospitalized for a heart evaluation from late August to September 1990 at St. Luke's Regional Medical Center, under the primary care of a cardiologist, William R. Wanner, M.D. He gave a history of shortness of breath of 30 years duration, which had worsened over the past 1 1/2 years. During the admission the veteran underwent cardiac catheterization and other diagnostic tests. Final diagnoses were an atrial septal defect, pulmonary hypertension, congestive cardiomyopathy, and normal coronary arteries. It was felt that the veteran was a candidate for a heart/lung transplant, and he was referred for a second opinion. Dr. Wanner reported in a January 1991 statement that the veteran had been referred to Abbott Northwestern Hospital and the physicians there agreed with his assess-ment, but the veteran did not want to stay for evaluation or commit himself to a transplant. The veteran was hospitalized in a VA medical center from March to April 1992 for evaluation of a congenital atrial septal defect with documented Eisenmenger's syndrome and a 15-month history of increasing exertional dyspnea, weakness and ankle swelling. Following clinical and laboratory evaluations and cardiology consultation, the diagnoses were atrial septal defects with Eisenmenger's complex with reverse right to left shunt and resultant pulmonary hypertension; hypoxemia and acrocyanosis with secondary polycythemia; and progressive pulmonary hypertension. Possible surgical repair of the atrial septal defect and a transplant operation were discussed, and a search was started for a hospital capable of performing the treatment. The veteran was admitted to a VA medical center on July 6, 1992, for heart-lung transplantation evaluation related to a congenital atrioseptal defect with Eisenmenger's syndrome, and pulmonary hypertension with resulting congestive cardiomyopathy. He gave a history of being told in service that he had a "hole in his heart," resulting in his service discharge. He reported he had no subsequent problems until about 20 months ago when, while working as a correctional officer, after jogging, he developed shortness of breath and other symptoms, and then sought treatment. Following a diagnostic workup, his cardiac diagnoses remained essentially unchanged. He was brought to the cardiac catheterization laboratory on July 10, 1992 for additional studies, and developed cardiac complications shortly thereafter, including respiratory distress. He was successfully stabilized and transferred to the coronary care unit, but he again developed cardiac complications shortly thereafter, which culminated in ventricular fibrillation. He did not respond to treatment and expired. Possible etiologies for his severe sudden desaturation were listed as (1) pulmonary embolus with increased pulmonary artery pressures (the presence of a large saddle embolus within the pulmonary artery had been demonstrated by echocardiogram); or (2) systemic vasodilation initiated by Valium and exacerbated by further desaturation. It was noted that both situations would have worsened oxygenation and would have precipitated a significant right to left shunt. A reviewing physician agreed with the above findings and a follow-up note added that, whether the veteran underwent cardiac catheterization or not, the outcome was invariably fatal with a saddle pulmonary embolism which he had developed. II. Analysis The Board initially finds that the appellant has presented well- grounded claims within the meaning of 38 U.S.C.A. § 5107(a). That is, she has presented claims which are not inherently implausible. The relevant evidence has been obtained by the RO and there is no further duty to assist the appellant in developing the facts pertinent to her claims. Id. A. Service Connection for Heart Disease for Accrued Benefits Purposes Upon the death of a veteran, periodic monetary benefits to which he was entitled on the basis of evidence in the file at the date of death, and due and unpaid for a period of not more than one year prior to death, may be paid to his spouse. 38 U.S.C.A. § 5121; 38 C.F.R. § 3.1000. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. Congenital or developmental defects are not diseases or injuries for VA compensation purposes. 38 C.F.R. § 3.303(c). During the veteran's 1956-1961 military service he was found to have an atrial septal defect of the heart, and this led to his discharge from service. The service department noted the condition preexisted service without aggravation therein. The medical evidence clearly shows that the atrial septal defect noted in service represented a congenital defect for which service connection is precluded. The service medical records show no superimposed heart disease which might be considered for service connection. 38 C.F.R. § 3.303(c); O.G.C. Precedent 82- 90, 55 Fed Reg 45711 (1990). In fact, the post-service medical records show no chronic acquired heart disease, superimposed on the congenital defect, until many years after service, and such has not been linked to any event of service. Rather, the additional heart disease reportedly was the result of the congenital atrial septal defect (i.e., the "hole in the heart," which had been present since birth). An acquired heart disease was not incurred in or aggravated by service, and may not be service-connected. It follows that the derivative claim for accrued benefits must fail. As the preponderance of the evidence is against the appellant's claim, the benefit-of-the-doubt doctrine is inapplicable, and service connection for heart disease for accrued benefits purposes must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet.App. 49 (1990). B. Service Connection for the Cause of the Veteran's Death To establish service connection for the cause of the veteran's death, the evidence must show that a service-connected disability (a disability incurred in or aggravated by service) was either the principal cause or a contributory cause of death. For a service-connected disability to be the principal (primary) cause of death, it must singly or with some other condition be the immediate or underlying cause or be etiologically related. For a service-connected disability to constitute a contributory cause, it must contribute substantially or materially; it is not sufficient to show that it casually shared in producing death, but rather it must be shown that there was a causal connection. 38 U.S.C.A. § 1310; 38 C.F.R. § 3.312. The death certificate and terminal hospital records show that the veteran died of complications associated with an underlying heart condition, which included a congenital atrial septal defect, as well as superimposed heart disease which developed years after service. As discussed earlier in this decision, the veteran's congenital atrial septal defect and post-service superimposed heart disease are considered non-service-connected. The sole established service-connected condition, residuals of a fractured right little finger, obviously played no role in the veteran's death. From these facts, it is clear that a service-connected disability neither caused nor contributed to death. The preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is inapplicable, and service connection for the cause of the veteran's death must be denied. 38 U.S.C.A. § 5107(b); Gilbert, supra. ORDER Service connection for heart disease for accrued benefits purposes is denied. Service connection for the cause of the veteran's death is denied. L. W. TOBIN 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.