VALVULAR HEART DISEASE (INCLUDING RHEUMATIC HEART DISEASE)

M. C. GRAHAM · 2026 · Case ID: A26038101

GRANTED

Summary

The veteran, who served from March 1978 to March 1981 and April 1982 to October 1987, appeals the denial of service connection for a bicuspid aortic valve and mitral valve prolapse, claimed as a bundle branch block. The veteran's service entrance examinations in July 1977 and April 1982 noted normal cardiac evaluations, though the July 1977 exam noted a precordial lift and systolic murmur, recommending a cardiac consult. Service treatment records from his second period of service noted an incomplete right bundle branch block in April 1983, with subsequent electrocardiograms showing progression of this condition and right axis deviation. The veteran contended his preexisting heart condition was aggravated by service. The Board found that while the veteran's heart condition was congenital, the evidence was not clear and unmistakable that it was not aggravated in service. A March 2025 private examination by Dr. P concluded it was more likely than not that the veteran's congenital heart conditions were aggravated by military service, citing the "rigors of military service" and the progression from an in-service bundle branch block to severe cardiac complications. The Board found this private opinion highly probative, noting the evidence was in equipoise regarding abnormally high progression due to aggravation. Consequently, service connection for the bicuspid aortic valve and mitral valve prolapse, status post surgery and stroke, is granted.

Rationale

Congenital heart condition diagnosed; Progressed at abnormally high rate due to aggravation in service; Private medical opinion found aggravation more likely than not

Special Benefit

NO SPECIAL BENEFIT

Docket No.

210816-179419

Full Decision Text

Citation Nr: A26038101
Decision Date: 04/23/26 Archive Date: 04/23/26

DOCKET NO. 210816-179419
DATE: April 23, 2026

ORDER

Entitlement to service connection for bicuspid aortic valve and mitral valve prolapse status post surgery and stroke, claimed as bundle branch block, is granted.

FINDINGS OF FACT

1. Clinical evaluation of the Veteran's heart was noted as normal upon service entrance examination on July 29, 1977, with the notation of precordial lift and systolic murmur and cardiac consult recommended "on return".

2. An August 8, 1977 cardiac work-up/report of past medical examination/treatment was completed by a physician to complete the Veteran's medical processing which noted the Veteran had "[s]plit 2nd heart sounds" and the prognosis of the condition was assessed as "good" with awareness of the environment of vigorous physical activity for extended period in a variety of climactic conditions. The following day, the Veteran was assessed as fit for service on his service entrance examination.

2. The Veteran has been diagnosed with congenital bicuspid aortic valve and mitral valve prolapse that "have evolved into advanced heart failure with documented findings including left ventricular dilation, cardiomegaly, aortic aneurysm, mitral valve [surgical] replacement, and a cardioembolic stroke."

3. The Veteran's undiagnosed congenital heart issues were exacerbated by the physical demands of military service.

CONCLUSION OF LAW

The criteria for entitlement to service connection for bicuspid aortic valve and mitral valve prolapse status post surgery and stroke, claimed as bundle branch block, are met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303.

REASONS AND BASES FOR FINDINGS AND CONCLUSION

The Veteran served on active duty from March 1978 to March 1981, and from April 1982 to October 1987. The Board thanks the Veteran for his service to our country.

In a February 2020 rating decision, the agency of original jurisdiction (AOJ), denied entitlement to service connection for a bicuspid aorta valve disability. In February 2021, the Veteran submitted a VA Form 20-0996, Decision Review Request: Higher-Level Review (HLR), and requested review of the February 2020 decision. In February 2021, the Higher-Level Reviewer determined that there had been a duty to assist error and transferred the claim to the Supplemental Claim decision review option for additional development.

In March 2021, the AOJ issued the supplemental claim decision on appeal, which found that new and relevant evidence had been received and denied the claim based on the evidence of record at the time of that decision.

In the August 2021 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Hearing docket. A Board hearing was held on April 2025.

Therefore, the Board may only consider the evidence of record at the time of the March 2021 AOJ decision on appeal, as well as any evidence submitted by the Veteran or representative at the hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a). If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the Board hearing, or (2) more than 90 days following the hearing, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.302(a), 20.801.

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claims, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

As an initial matter, the Board notes that the Veteran's representative for purposes of this appeal is attorney Patrick Haynes. An August 23, 2021 letter informed him that his appeal was being placed on the Board's docket and that he had 90 days from the date of the August 16, 2021, VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement) or until the Board decision was issued to request a
3.2501. If the evidence is new and relevant, VA will issue another decision on the claims, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

As an initial matter, the Board notes that the Veteran's representative for purposes of this appeal is attorney Patrick Haynes. An August 23, 2021 letter informed him that his appeal was being placed on the Board's docket and that he had 90 days from the date of the August 16, 2021, VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement) or until the Board decision was issued to request a change in representation. At that time, he was represented by a veterans service organization. The pertinent regulation states that after the 90-day period, the Board will not accept a request for a change in representation except when the appellant demonstrates on motion that there was good cause for the delay. 38 C.F.R. § 20.1304.

After the expiration of the 90-day period, in October 2024, the Veteran submitted a new power of attorney (POA) in favor of attorney Patrick Haynes who represented the Veteran at the time of the April 2025 hearing. Thereafter, on June 12, 2025, again after the 90-day period had expired, the Veteran submitted a new power of attorney (POA) in favor of a different private attorney. The Board recognizes that the Veterans Benefits Administration, not the Board, acknowledged the June 12, 2025, filing as a revocation of representation by attorney Haynes; however, as noted above, there are specific requirements regarding changes of representation with respect to appeal filed at the Board. As the June 2025 change in representation was submitted over 90 days from the August 16, 2021, VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), and as the Veteran has not submitted good cause for his most recent change in representation, attorney Haynes remains the representative for purposes of this appeal. 38 C.F.R. 20.1304(b).

Service Connection

Entitlement to service connection for a heart disability, diagnosed as bicuspid aortic valve and mitral valve prolapse, claimed as bundle branch block.

Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service-the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 38 F.3d 1163, 1167 (Fed. Cir. 2004)). The absence of any one element will result in denial of service connection.

Service connection may also be granted for any disease initially diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d).

In addition, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including cardiovascular-renal disease, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309.

For the showing of a chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).

Every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence
chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).

Every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). Only conditions recorded on examination reports are considered "noted" at entry into service. 38 C.F.R. § 3.304(b). History provided by the Veteran of the pre-service existence of conditions recorded at the time of the entrance examination does not, in itself, constitute a notation of a preexisting condition. 38 C.F.R. §§ 3.304(b)(1); Paulson v. Brown, 7 Vet. App. 466, 470 (1995); Crowe v. Brown, 7 Vet. App. 238, 246 (1995).

Generally, congenital or developmental defects are not considered to be diseases or injuries for VA compensation purposes. See 38 C.F.R.§§ 3.303(c), 4.9; Winn v. Brown, 8 Vet. App. 510, 516 (1996). However, service connection may still be granted for congenital diseases which either (1) first manifested during service, or (2) which pre-existed service and progressed at an abnormally high rate due to aggravation in service. See VAOPGCPREC 82-90 (July 18, 1990). A congenital, developmental, familial, or hereditary condition that is progressive in nature (i.e., which can worsen or improve over time) is a "disease process." See O'Bryan v. McDonald, 771 F.3d 1376, 1380 (Fed. Cir. 2014).

Even if it is determined during service that a Veteran suffers from a congenital disease, VA cannot simply assume that, because of its congenital nature, a congenital disease must have preexisted service. Thus, the presumption of soundness still applies to congenital diseases that are not noted at entry. Quirin v. Shinseki, 22 Vet. App. 390, 396-397 (2009). If the presumption of soundness at entrance attaches, VA must show by clear and unmistakable evidence that the congenital disease preexisted service. Monroe v. Brown, 4 Vet. App. 513, 515 (1993).

Clinical evaluation of the Veteran's heart was noted as normal upon service entrance examination on July 29, 1977, with the notation of precordial lift and systolic murmur and cardiac consult recommended "on return". An August 8, 1977 cardiac work-up/report of past medical examination/treatment was completed by a physician to complete the Veteran's medical processing which noted the Veteran had "[s]plit 2nd heart sounds" and the prognosis of the condition was assessed as "good" with awareness of the environment of vigorous physical activity for extended period in a variety of climactic conditions. The following day, the Veteran was assessed as fit for service on his service entrance examination. Therefore, he is presumed to have been in sound condition at the start of his first period of active service.

A February 1981 separation examination, from his first period of active duty, reflects a normal clinical evaluation of his heart.

Treatment records between his two periods of active duty service reflect a right bundle branch block. See July 1981 and January 1982 treatment records.

An April 1982 entrance examination, into his second period of active duty, reflects a normal heart clinical evaluation. Therefore, he is presumed to have been in sound condition at the start of his first period of active service.

In an April 1983 electrocardiographic service treatment record, an incomplete right bundle branch block was noted. A November 1983 examination noted that the Veteran had been evaluated for a right bundle branch block in 1982 which was thought to be congenital in nature with no symptomatology. A November 1983 electrocardiographic record noted abnormal tracing, right bundle right axis deviation. A December 1985 electrocardiographic record noted a left atrial abnormality, right bundle branch block, and right axis deviation. In a July 1986 electrocardiographic record normal sinus rhythm, right bundle branch block and right axis deviation were noted. A January 1987 electrocardiographic record noted normal sinus rhythm and an incomplete right bundle branch block. A September 1987 electrocardiographic record noted normal sinus rhythm with right bundle branch block and abnormal EKG. A September 1987 separation examination reflected a normal heart clinical evaluation. It was noted that the Veteran had a right bundle branch block. The Veteran denied any heart symptomatology in a report of medical history completed at that time.

The Veteran contends that his preexisting heart disability was aggravated by service. See February 2021 Statement.

In the March 2021 rating decision on appeal, the AOJ favorably found that the Veteran (1) had been diagnosed with a disability in light of a March 2021 VA examination that showed a diagnosis of bicuspid aortic valve, (2) there was a qualifying event, injury, or disease that had its onset during service as service treatment records document a right bundle branch block by EKG on July 2, 1986, and (3) the claimed issue existed prior to military service as his July 1977 enlistment exam notes a precordial lift and systolic murmur. See 38 C.F.R. § 3.104(c).

The Board does not find that the Veteran's heart disability was noted at entrance to either period of service. Therefore, the presumption of soundness attached. However, the evidence is clear and unmistakable that the Veteran had a preexisting congenital heart disability. However, the evidence is not clear and unmistakable that the preexisting heart disability was not aggravated in service. Therefore, the presumption of soundness has been rebutted with respect to this disability.

VA's Office of General Counsel has distinguished between congenital or developmental defects, for which service connection is precluded by regulation, and congenital or hereditary diseases, for which service connection may be granted, if initially manifested in or aggravated by service. See VAOPGCPREC 82-90, VAOPGCPREC 67-90. The VA General Counsel draws on medical authorities and case law from other federal jurisdictions and concludes that a defect differs from a disease in that a defect is "more or less stationary in nature", while a disease is "capable of improving or deteriorating." See VAOPGCPREC 82-90 at para. 2.

The Board finds that the Veteran's bicuspid aortic valve and mitral valve prolapse are congenital diseases, as that term is understood when it applies to VA benefits, as the medical evidence is clear that they are capable of worsening. Although a March 2025 private examiner, Dr. P, noted in a report, submitted within 90 days of the Veteran's Board hearing, that the Veteran's cardiac condition included "congenital heart defects," her report is clear that bicuspid aortic valve and mitral valve prolapse deteriorates: "[the Veteran] has experienced a progressive decline in cardiac function"; "[h]is condition has evolved into advanced heart failure with documented findings including left ventricular dilation, cardiomegaly, aortic aneurysm, mitral valve [surgical] replacement, and a cardioembolic stroke." Thus, for VA purposes, the Veteran's heart disability is a congenital disease, not a congenital defect.

Service connection is warranted for congenital diseases which either (1) first manifested during service, or (2) which pre-existed service and progressed at an abnormally high rate due to aggravation in service. See VAOPGCPREC 82-90 (July 18, 1990). Here, the Board finds that the medical evidence supports a finding that the Veteran's heart disability progressed at an abnormally high rate due to aggravation in service. This is so because the private examiner stated that the "rigors of military service likely exacerbated the progression of the [Veteran
, and a cardioembolic stroke." Thus, for VA purposes, the Veteran's heart disability is a congenital disease, not a congenital defect.

Service connection is warranted for congenital diseases which either (1) first manifested during service, or (2) which pre-existed service and progressed at an abnormally high rate due to aggravation in service. See VAOPGCPREC 82-90 (July 18, 1990). Here, the Board finds that the medical evidence supports a finding that the Veteran's heart disability progressed at an abnormally high rate due to aggravation in service. This is so because the private examiner stated that the "rigors of military service likely exacerbated the progression of the [Veteran's] heart disease, leading to the need for mitral valve replacement and increasing his risk for life-threatening cardiac events."

The Veteran was afforded a VA examination in March 2021. A diagnosis of bicuspid aortic valve was made. The examiner noted that the Veteran's heart condition was congenital. The examiner opined that it was less likely than not incurred in or caused by the claimed in-service injury, event or illness. As rationale, the VA examiner noted that the Veteran's heart condition is a congenital condition, he was born with it, therefore it is less likely caused by the Veteran's military duties during service. The VA examiner did not address aggravation of a preexisting disease; therefore, this medical opinion is afforded no probative value with respect to in service aggravation.

Also of record is the March 2025 private examination report from Dr. P, a licensed physician. She noted that she had reviewed the Veteran's medical records, including in-service records. She indicated that according to his medical records, the Veteran has a history of congenital bicuspid aortic valve (BAV) and mitral valve prolapse (MVP), has experienced a progressive decline in cardiac function that has severely impacted his health and quality of life. The physician stated that clinical examinations and imaging have documented persistent findings indicative of his deteriorating condition. The private physician stated that the Veteran's medical history clearly demonstrates a severe and progressive cardiac condition, originating from undiagnosed congenital heart defects that were exacerbated by the physical demands of military service. His heart failure, left ventricular dysfunction, aortic aneurysm, and mitral valve disease have led to life-threatening complications, including stroke.

Dr. P. noted that the rigors of military service likely exacerbated the progression of Veteran's heart disease, leading to the need for mitral valve replacement and increasing his risk for life-threatening cardiac events. She concluded that it is more likely than not that the Veteran's congenital heart conditions were aggravated by his military service. The failure to diagnose and manage these conditions during service contributed to the development and acceleration of his severe cardiac complications, ultimately leading to heart failure, aneurysm formation, and stroke. She explained that the Veteran's medical history reveals a progression from an in-service bundle branch block (BBB) to significant cardiovascular events, including bicuspid aortic valve (BAV) disease requiring surgery and a subsequent stroke. The examiner concluded her report, noting that after a review of the Veteran's records, it is at least as likely as not that his bicuspid aortic valve, subsequent heart failure, aortic aneurysm, and stroke are connected to his in-service bundle branch block and congenital heart defects, which was left untreated. The progression from conduction abnormalities to structural heart disease, as supported by medical literature, demonstrates a link between his in-service cardiac condition and his current severe cardiovascular complications. Medical studies were provided.

The Board finds that the March 2025 private opinion is entitled to high probative value on the issue of aggravation of the Veteran's congenital heart disease. As the evidence is at least in equipoise that the Veteran's preexisting heart disease progressed at an abnormally high rate due to aggravation in service, entitlement to

service connection for bicuspid aortic valve and mitral valve prolapse status post surgery and stroke is warranted.

M. C. GRAHAM

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board A. M. Clark, Counsel

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.

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