RECORD OF PROCEEDINGS

PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXX BRANCH: marine corps

CASE NUMBER: PD201000979 SEPARATION DATE: 20041231

BOARD DATE: 20110615

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SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty Cpl (0352, Antitank Assault Guided Missileman) medically separated from the Marine Corps in 2004. The medical basis for the separation was bicuspid aortic valve (BAV), congenital, with related chest pain. He did not respond adequately to perform within his military occupational specialty or to participate in a physical fitness test. He was placed two periods of limited duty and underwent a Medical Evaluation Board (MEB). BAV and chest pain (exertion related) were the only conditions on the MEB’s submission to the Physical Evaluation Board (PEB). The PEB rated the BAV at 10% and related chest pain as a category II condition, with application of SECNAVINST 1850.4E and the VA Schedule for Rating Disabilities (VASRD). The CI made no appeals and was medically separated with a 10% disability rating.

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CI CONTENTION: “In July of 2003, the medical unit at my battalion found I had developed a heart murmur. Exams in 1990 (MEPS), 1995 (EAS), 1996 & 1999 (Commercial Driver's License) and 2003 (MEPS) showed no murmur. At MEPS in Raleigh, NC (March 2003), because I was 30 years-old, I was taken aside for a more intense screening, which focused mostly on my heart. No doctor heard or noted any abnormality. (Continued in Item 12) After my murmur was discovered, I was diagnosed with a "Functionally-Bicuspid Aortic Valve" and "Aortic Regurgitation." Military doctors' diagnoses of the regurgitation ranged from "mild/moderate to moderate" at Camp Lejeune and "severe upon exertion" at Bethesda Naval Hospital. One civilian examination diagnosed the regurgitation as "moderate/severe" and another civilian specialist diagnosed it as "severe." My diagnosis of "functionally-bicuspid" shows that my valve is properly formed but is now not properly working. After eighteen months of physical evaluation, I was separated with a rating of 10%. When I questioned this finding, I was advised to take it before they changed their minds and gave me nothing because my problem was "congenital." I truly believe my condition is not a birth defect because it would have shown in the multiple examinations I had before it was discovered. Furthermore, I did all of the physical requirements of Marines before I had the chest pains and diagnosis but I could not keep up after my diagnosis. I accept that my physical condition, therefore, must label me as unfit for further service. However, I also believe that a separation with a 10% rating does not make sense. If it was only worthy of 10%, I think I would have been able to stay and continue my service with such a mild disability. I personally think the rating should have been much higher since my problem is severe, involves my heart and is not a birth defect.”

RATING COMPARISON TABLE:

ANALYSIS SUMMARY: The CI contends that his condition is not congenital. BAV is a congenital condition which results when the aortic valve has two rather than the normal three leaflets. Although this is a congenital condition, is not unusual for bicuspid aortic valve to be diagnosed later in life once the valve begins to malfunction. Flow through the abnormal valve creates turbulence and leads to gradual valvular scarring and thickening. Over time, this leads to a leak in the valve called aortic insufficiency and to a narrowed outlet called aortic stenosis. As the condition progresses, murmurs develop. Prior to the development of the murmurs an echocardiogram (ECHO) would be required to diagnose the condition. It is not likely that subjects would have an ECHO without some sign or symptom, thus the condition is usually diagnosed during adulthood after the condition has progressed to the point of valvular dysfunction.

The Board acknowledges the sentiment expressed in the CI’s application, i.e., that there should be additional disability assigned for the gravity of his condition and predictable future consequences which merit consideration for a higher separation rating. The role of the Disability Evaluation System (DES) considers all of the service member's medical conditions, compensation can only be offered for those medical conditions that cut short a service member's career, and then only to the degree of severity present at the time of separation. However, the Department of Veterans Affairs, operating under a different set of laws (Title 38, United States Code), is empowered to periodically re-evaluate veterans for the purpose of adjusting the disability rating should the degree of impairment vary over time.

Bicuspid Aortic Valve, Congenital With Related Chest Pain. The CI developed chest pain, tightness, and shortness of breath in June 2003. A diagnosis of congenital BAV was made. Testing included a graduated treadmill stress test, an ECHO, a trans-esophageal echocardiogram (TEE) and a stress ECHO and pulmonary function testing. Excellent exercise tolerance was noted; he achieved 14 metabolic equivalents. There was no left ventricular hypertrophy (LVH) and the ejection fraction was 65% on initial ECHO and 55% on TEE. On the initial ECHO seventeen months prior to separation mild left ventricle (LV) diastolic dilatation was noted. A TEE two months later showed neither dilation nor hypertrophy. A stress ECHO one month later also showed normal LV/end diastolic volume (no dilatation). Another ECHO three months prior to separation noted mild systolic LV dilatation. A cardiology evaluation dated 21 September 2004 three months prior to separation noted that he had no dyspnea on exertion (DOE), could run two miles and played tennis without symptoms. At the time of the MEB evaluation of 25 August 2004 four months prior to separation the CI’s condition was stable on atenolol with no symptoms at rest. The CI had noted some decreased exercise tolerance which was thought to be secondary to the atenolol. His physician switched him to ramipril; however, he had symptoms of shortness of breath and dizziness, and the atenolol restarted and the eamipril discontinued. The examiner noted a regular rate and rhythm, a 2/6 diastolic crescendo/decrescendo murmur best heard at the right upper sternal border and left lower sternal border, but no heaves, lifts, rubs or thrills were noted. There was neither chest wall tenderness nor jugular venous pulse. The examiner opined that the post-exertional chest pain was likely related to the aortic regurgitation.

The VA compensation and pension exam was performed on 18 November 2004 one month prior to separation by an internist. The only symptom documented was post-exertional chest pain. This examiner also noted a 2/6 systolic murmur at the cardiac base consistent with aortic stenosis, which was also noted on the stress ECHO. The examiner believed the CI’s condition could best be classified at this time as bicuspid aortic valve with associated systolic and diastolic murmur of aortic stenosis and aortic insufficiency. The PEB and VA both coded the BAV condition with chest pain as 7000 (valvular heart disease), rated 10%. On appeal to the VA, the disability review officer upheld the VA adjudication. Exercise tolerance was excellent on testing and no LVH was present. In four ECHOs, LV dilatation was noted in systole on one and in diastole on another; however, dilation was not present on either the TEE, more sensitive than the trans-thoracic ECHO, or the stress ECHO. After due deliberation and in consideration of the totality of the evidence, the Board concluded that there the preponderance of evidence did not favor the consistent presence of either dilation or hypertrophy and that there was insufficient cause to recommend a change from the PEB fitness adjudication for the BAV condition.

Remaining Conditions. The other condition identified in the DES file was the history of a right wrist fracture in 1994. Several additional non-acute conditions or medical complaints were also documented. None of these conditions were clinically active during the MEB period, carried attached profiles, or were implicated in the commander’s assessment. These conditions were reviewed by the action officer and considered by the Board. It was determined that none could be argued as unfitting and subject to separation rating. The Board therefore has no reasonable basis for recommending any additional unfitting conditions for separation rating.

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BOARD FINDINGS: IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication. In the matter of the BAV with chest pain condition and IAW VASRD §4.104, the Board recommends no change in the PEB adjudication, by a 2:1 vote. The minority voter favored a 30% disability rating for the presence of dilatation on two of four tests, but did not elect to submit a minority opinion. The Board unanimously agrees that there were no other conditions eligible for Board consideration which could be recommended as additionally unfitting for rating at separation.

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RECOMMENDATION: The Board therefore recommends that there be no recharacterization of the CI’s disability and separation determination.

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The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20100820, w/atchs.

Exhibit B. Service Treatment Record.

Exhibit C. Department of Veterans' Affairs Treatment Record.

Deputy Director

Physical Disability Board of Review

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW

BOARDS

Subj: PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATION

ICO XXXX, FORMER USMC

Ref: (a) DoDI 6040.44

(b) PDBR ltr dtd 1 Jul 11

I have reviewed the subject case pursuant to reference (a) and, for the reasons set forth in reference (b), approve the recommendation of the Physical Disability Board of Review Mr. XXXX’s records not be corrected to reflect a change in either his characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board.

Assistant General Counsel

(Manpower & Reserve Affairs)