Citation Nr: 22010048 Decision Date: 02/22/22 Archive Date: 02/22/22 DOCKET NO. 16-63 484 DATE: February 22, 2022 ORDER Entitlement to service connection for a heart disorder of atrial fibrillation, status post ablation, and cardiomegaly is denied. FINDINGS OF FACT 1. A benign heart murmur preexisted service was noted upon entry onto active duty service and was not aggravated by service, with competent medical evidence finding that this was a static defect and not a disability. 2. The Veteran's heart disorder of atrial fibrillation, status post ablation, and cardiomegaly are not secondary to service-connected post-traumatic stress disorder (PTSD), to include medication to treat PTSD and are not otherwise related to an in-service injury or disease. CONCLUSION OF LAW The criteria for service connection for a heart disorder of atrial fibrillation, status post ablation, and cardiomegaly due to service or secondary to service-connected PTSD have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active duty service from June 1991 to October 1991, with additional reserve service. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued by a Department of Veterans' Affairs (VA) Regional Office (RO) in September 2013. The Veteran testified before the undersigned Veterans Law Judge at a November 2018 hearing. A copy of the hearing transcript has been reviewed and associated with the claims file. This matter was previously before the Board in June 2019, June 2021 and October 2021 and was remanded for further evidentiary development. Heart disability status post ablation The Veteran contends that her current heart disability is due to her service, or, alternatively, has resulted from her service-connected posttraumatic stress disorder. She testified at her November 2018 Board hearing that she was first diagnosed with atrial fibrillation (Afib) in 2006, and it was further pointed out by her representative that she was noted to have a heart murmur on entrance examination. She testified that during an anxiety attack, her heart beats so fast that she has sought emergency treatment, indicating that she has been to the ER at least 50 times, where she was told she needed to calm down. She also testified as to having issues with hypertension that had been previously denied service connection. She gave a history of having undergone ablation, thinking it was around 2009, and speculated that the procedure was related to issues with her nerves. Her symptoms improved after the ablation, but she still gets episodes of Afib at times. She believed that her symptoms were improved by anti-anxiety medications such as Clonazepam. See November 2018 Hearing Transcript, pg. 4-10. At her prior hearing before a DRO in June 2016 she also suggested her heart symptoms were related to her PTSD and indicated that anti-anxiety medications helped her symptoms. Transcript of 6/16 hearing at pg. 6-9. In statements submitted in July 2011 and March 2013, the Veteran has asserted that she has gained weight because of her PTSD medications, including, but not limited to, olanzapine (Zyprexa), nefazodone (Serzone), and mirtazapine(Remeron). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303. Service connection may also be granted for a disease first diagnosed after discharge 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). Under 38 C.F.R. § 3.303 (b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage v. Gober, 10 Vet. App. 488, 495-97 (1997). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage, 10 Vet. App. at 495-96. For veterans who have served 90 days or more on or after December 31, 1946, certain chronic diseases, such as cardiovascular diseases are presumed to have been incurred in service if such manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1133; 38 C.F.R. §§ 3.307 (a), 3.309(a). A nexus between a current disability and an in-service injury or event may be established by evidence of continuity of symptomatology, if the condition is a chronic disease enumerated under 38 U.S.C. § 1101. Walker v. Shinseki, 708 F.3d 1331, 1338-40 (Fed. Cir. 2013). With chronic diseases shown as such in service, or within the presumptive period after service, so as to permit a finding of service connection, subsequent manifestation of the same chronic disease at any later date, however remote, are service connected unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303 (b). Every Veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects noted at the time of the examination, acceptance and enrollment, or where clear and unmistakable evidence such as to warrant a finding that the disease or injury existed before acceptance and enrollment, and was not aggravated by such service. 38 U.S.C.A. § 1111. A preexisting injury or disease is considered aggravated by military service where there is an increase in disability during service, absent a specific finding that the increase in disability was due to the natural progress of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306 (a). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C.A. § 1153; 38 C.F.R. §§ 3.304, 3.306 (b). Temporary or intermittent flare-ups during service of a preexisting injury or disease are not sufficient to be considered "aggravation in service" unless the underlying condition, as contrasted to symptoms, is worsened. Jenson v. Brown, 4 Vet. App. 304, 306-307 (1993) (citing Hunt v. Derwinski, 1 Vet. App. 292 (1991)). However, if an increase in disability is shown, clear and unmistakable evidence is required to rebut the presumption of aggravation. 38 C.F.R. § 3.306 (b). Congenital and developmental defects are not disabilities, injuries, or diseases within the meaning of Agency regulations for disability compensation benefits. As such, the presumption of soundness does not attach to those claims. 38 C.F.R. 4.9 ; Quirin v. Shinseki, 22 Vet. App. 390, 396-97 (2009). However, VA's General Counsel has held that there is a distinction between "diseases" and "defects" for congenital and developmental conditions. Congenital diseases may be recognized as service connected if the evidence as a whole shows aggravation in service. On the contrary, a congenital defect is not able to be connected to service. 38 C.F.R. 3.303 (c). In a narrow scope of cases, service connection may be established for congenital defects upon a showing of an additional disease or injury superimposed upon such defect during service. VAOGCPREC 82-90.Service connection may also be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. The question for the Board is whether the Veteran has a current disability that was incurred or aggravated in active service or is proximately due to or the result of, or aggravated beyond its natural progress by service-connected disability. Service treatment records (STRs) show that on reserve entrance examination in April 1991, a soft systolic heart murmur was noted. The accompanying report of medical history initially drafted in April 1991, indicated that a cardiac consult was done in May 1991, with an impression of benign murmur recorded on June 5, 1991. An April 26, 1991 cardiac consult for a soft systolic murmur, asymptomatic, noted a negative cardiac review of systems, noting her to be a nonsmoker who exercised regularly. Following examination, the impression was benign murmur. None of the other STRs suggested any heart issues or injury to the heart. Social Security (SSA) records included a Disability Report questionnaire of an unclear date, in which the Veteran listed illnesses impacting her ability to work. These included heart valve damage and severe depression, Symptoms included pain in the chest. These claimed illnesses, injuries or conditions first bothered her on July 10, 1998 and she stopped working on December 10, 1998 due to severe depression and heart pain. A March 2000 Internal Medicine Report in the SSA records noted a record of chest pain and shortness of breath on walking one block or 1 flight stairs, and a history of fen-phen usage. She was noted to have taken fen-phen to reduce her weight for about 6 months 2 and a half years ago, and a history of chest pain and shortness of breath for the last 2 years. She also had obesity, depression and diabetes mellitus controlled with diet. She reported that she had an EKG done but no copy was available. She had no history of myocardial infarction or cerebrovascular accident. She was noted to be taking medications for depression. Other SSA records included a portion of a disability questionnaire filled out and signed by a physician on March 16, 2000, which noted that an EKG was unremarkable. An undated portion of a Social Security explanation of determination, which was unfavorable, noted that she claimed being unable to work due to depression and heart valve damage. Special testing of heart showed that it was functioning satisfactorily. Her chest was normal, and lungs were clear. No symptoms of heart failure were shown at time of exam. The Veteran was noted to be overweight. Social Security records addressing psychiatric disabilities included an August 2003 mental status evaluation that described the Veteran as having gained 100 pounds over the last year deemed to be likely a combination of medication and lack of exercise. She was also noted to be morbidly obese. Private treatment records show that the Veteran was treated in the hospital for paroxysmal atrial fibrillation (Afib) in November 2005 that was converted to sinus rhythm after IV administration of medication. There were no identifying precipitating factors except stress and no risk factor unless hyperthyroidism. In March 2006 the Veteran was seen in a private emergency department for Afib. The instruction sheet for this visit indicated that an important part of her present problem was from anxiety and emotional distress. It noted that emotional upsets can cause many different physical symptoms including chest or stomach pain, fluttering heartbeat, passing out, breathing difficulties and headaches. Regarding the Afib she was diagnosed with, it was noted that this is a disturbance in the rhythm of the heartbeat and that treatment may include medications to regulate the heartbeat. It was also recommended that she avoid stimulants such as caffeine, nicotine, alcohol, decongestants, and diet pills. VA treatment records from November 2006 addressing mental health issues including PTSD included a diagnosis of Afib, while in December 2006 she was diagnosed with coronary artery disease. Private cardiovascular group records show treatment for cardiac symptoms including paroxysmal Afib and chest pain in late 2009 and throughout 2010. A December 31, 2009 record revealed she was admitted for Afib with a history it for several years and she reported experiencing palpitations at onset of each episode. She reported a history of treating them by getting them converted with Cardizem at the ER. Precipitating symptoms included stress and eating ice. She had eaten a lot of ice on the previous day and went into Afib. She denied seeing a cardiologist and had an echocardiogram a year ago that was normal. Her last Afib episode was 1 or 2 years ago which resolved after 2 drips of Cardizem. Following evaluation which included EKG showing normal rhythm, she was assessed with Afib, paroxysmal, status post pulmonary vein isolation with first recurrence recently. PTSD and obesity were also noted. She was noted to be aware that her weight was contributing to her illness and was motivated to lose weight. In January 2010 she was seen for followup with the ER and a doctor for evaluation of paroxysmal Afib with a history of high blood pressure when she weighed more and recently low blood pressure on Atenolol. She had a history of paroxysmal Afib with the last episode over 2 years ago. She had gone into Afib on New Year's Eve after eating ice and it converted to sinus rhythm after being given IV treatment with Cardizem. She also was noted to have PTSD and sleep apnea, but could not wear a mask. On testing her ECG was in sinus rhythm and looked like a normal tracing. The impression was paroxysmal Afib with very low CHADS score and only borderline blood pressure. She also had PTSD and sleep apnea. In February 2010 she was seen again with a history of having gone into Afib after drinking water and taking pills earlier in the day with ECG confirming Afib of about 119 beats per minute without ST/T wave changes. Plans were made to send her to the ER to be put on IV Cardizem to see if she converted spontaneously. On examination her EKG was in Afib, with an impression of recurrent paroxysmal Afib given after clinical exam. Her chest X-rays from February 2010 yielded an impression of no acute cardiopulmonary findings. The February 2010 records also noted findings of sleep apnea and PTSD. In May 2010 follow up she was noted to have an echocardiogram that was a technically difficult study, normal, and sleep study which showed snoring without apnea. She had no symptoms or recurrence of Afib since January and February. She was diagnosed with paroxysmal Afib in sinus rhythm now, normal echocardiogram with mildly elevated PA pressure and negative sleep study. She continued to have a diagnosis of PTSD. She was also diagnosed with borderline blood pressure which was very stable on the day of visit. Later in August 2010, she was seen for a walk in visit with complaints of chest pain, with a history of paroxysmal Afib but with atypical chest pain described as sharp, twingy and lasting only a few seconds. She also was having muscle twitching facially. Following examination she was assessed with atypical chest pain with facial muscle twitching, paroxysmal Afib in normal sinus rhythm, normal echocardiogram with mild elevated pulmonary artery pressure, PTSD and borderline blood pressure, stable today. In December 2010 she returned with a history of having been in the ER for palpitations again, and was now requesting ablation treatment. She had never been on antiarrythmics drugs and plans were made for her to start such drugs. Chest X-rays taken in December 2010 for shortness of breath and palpitations were unremarkable. Private cardiac treatment records from 2011 showed continued issues with episodes of Afib, with a July 2011 record showing he was hospitalized and treated with a Cardizem drip for chest palpitations and history of paroxysmal Afib. In August 2011 he was seen for management of paroxysmal Afib with the most recent episode 2 weeks ago treated at the ER. This was his first episode in months. Echocardiogram of February 2010 was normal with EF of 60%, normal left atrium and no significant valvular heart disease. The diagnosis continued to be Afib, paroxysmal. On September 13, 2011 she underwent EP study and ablation for the paroxysmal Afib and also underwent successful pulmonary vein isolation using cryotherapy with incidental findings of persistent left superior vena cava. On followup in November 2011, status post pulmonary vein isolation in September 2011 her EKG showed normal rhythm and she was diagnosed with paroxysmal Afib, status post pulmonary vein isolation. Further followup in November 2012 for the Afib revealed that she had remained in normal rhythm and did not have any recurrence of symptoms since her last visit in early November. However she has noted pulse a higher range than previously. EKG was in sinus rhythm. Records from January 2013 following show that she was treated for her paroxysmal Afib for the first time since her ablation in September 2011. She did quite well until recently when she had an episode of Afib from which she was promptly cardioverted to normal rhythm. These days she felt a lot of anxiety and stress. She believed that this was one of the triggers and her weight was noted to be contributing significantly to her heart disorder related illness. However she was motivated on a path to ideal body weight. Since her cardioversion, she has not had any recurrence. Her EKG revealed normal rhythm. The impression was A fib paroxysmal, s-p pulmonary vein isolation with first recurrence recently. She was also diagnosed with fibromyalgia, PTSD, and obesity. VA treatment records also reveal recurrent episodes of heart palpitations and Afib. These include emergency records in October 2006 for complaints of heart palpitations and panic attack symptoms which resolved on arrival to the ER and a heart rate from 130-140 beats per minute, slowing to 100, without chest pain or shortness of breath. The assessment was palpitation and Afib, associated with recurrent episodes of panic attacks. There were no chest pains at this time and the Trop I <0.1. EKG shows A-fib without any obvious ischemic changes. In November 2006 she was referred to the VA cardiology clinic due to paroxysmal Afib with a history of palpitations since 1992, and was first told of Afib since November 2005. The Veteran gave a history of the Afib being brought on by anxiety, but episodes have decreased with the last one a month ago and a history of a stress test 2 months ago where she said she "did fine." Following examination, she was assessed with paroxysmal Afib via history and documented on ECGs with further workup planned. Questions were raised whether she would benefit from therapy to maintain sinus rhythm. Weight loss was also recommended but she declined dietician consult. A November 2006 echocardiogram report indicated that the mitral valve was grossly normal, the aortic valve appeared structurally normal, the left atrium was normal and right atrium was not well visualized. In a December 2006 VA record addressing Afib, the Veteran said that episodes were brought on by anxiety and eating ice and episodes lasted 1-2 hours and resolved with some IV medicine that the ER gave her. The last episode was a week earlier when she was eating ice. She also had episodes when having panic attacks. A January 2007 cardiology record also noted her reports of stress and eating ice at a restaurant triggered her Afib and she did not plan to eat the ice there again although she craved ice and was getting her iron replaced to help that. She stated that when she gets angry thinking about the traumas that triggered her PTSD she can "think herself into Afib." The assessment was intermitted AFIB. It was noted that ice has been known to trigger Afib and her other very few episodes all sounded vagal too. Records from April 2007 indicated that she was reminiscing about her military trauma when she lost balance and fell and was taken to a private hospital where she was found to be in Afib. She felt her Afib was brought on by anxiety. VA cardiology records from June 2007 noted that she had one episode of Afib recently requiring an ER visit, but she found that if she keeps herself covered in blankets when eating ice, she will not go into Afib. She recognized that her ice eating was abnormal, and it was called PICA and there were discussions whether it might be related to PTSD. She was also noted to be trying to lose weight and lost several pounds so far. She continued to be having a history of panic attacks with Afib precipitated by eating ice as reported in August 2007. She was assessed with Afib with no recent events since discontinuing ice. A September 2007 record indicated she called in with complaints of palpitations around 9 pm. Other records including a December 2011 problem list indicated that Afib was included in the problem lists. Subsequent VA treatment records from 2013 through 2020 showed continued issues with recurrent Afib. In April 2013 she was noted to have a BMI that indicated obesity and the risks of obesity including heart disease were discussed. In July 2013 she was noted to have a history of Afib status post ablation in 2011 with some irregular heartbeats noted in February but regular heartrate since cardioversion. In October 2015 the Veteran complained of side effects of psychotropic medications stating that hydroxyzine gave her palpitations and heartburn. In April 2018 she was seen for increased heart rate and she complained of Gabapentin having caused muscle twitching. The Veteran underwent a VA examination for heart conditions in October 2016. The diagnoses given in this examination were valvular heart disease and Afib status post ablation and cardioversion. The medical history given for the Afib status post heart ablation included an onset of symptoms in 2001, with several Afib episodes that would either convert by themselves or she would go to the ER until diagnosed. For the second diagnosis of valvular heart disease, the etiology was mitral/tricuspid valve abnormality. No other heart disorders were diagnosed nor was there a history of such, including myocardial infarction or congestive heart failure. After a review of the Veteran's records and an in-person examination, the examiner opined the claimed condition is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected PTSD. The examiner acknowledged the Veteran's cardiac ablation due to cardiac arrhythmia/atrial fibrillation, explaining that atrial fibrillation occurs due to an underlying cardiac pathology which affects the atrial myocardium. While PTSD can cause palpitations due to anxiety or panic attacks, it is less likely to cause atrial fibrillation, and furthermore, PTSD is not an established cause of atrial fibrillation or cardiac arrhythmia. Again the examiner attributed atrial fibrillation or cardiac arrhythmia to an underlying cardiac pathology. The examiner added that valvular heart disease is less likely than not (less than 50 percent probability) proximately due to PTSD because PTSD is not an established cause for valvular heart disease. Although this examiner provided an adequate secondary service connection opinion on the question of whether the service-connected PTSD caused a currently diagnosed heart disorder, this examiner failed to provide an opinion regarding whether there was aggravation of the heart disorder by the service connected PTSD. Thus it was deemed necessary by the Board in June 2019 to remand this matter for further examination. The Veteran underwent another VA examination for heart conditions in February 2021, with the reports entered in the claims file in March 2021. The diagnoses were of atrial fibrillation status post ablation with date of diagnosis in 1997, with a second diagnosis of status post ablation cardiac for atrial fibrillation diagnosed in 2014. No other heart disorders were diagnosed including the valvular heart disease that had been previously diagnosed in the 2016 examination. In the remarks section, the examiner noted that there was no evidence of bruits. After an in-person examination and review of the Veteran's record, the examiner found the claimed condition was less likely than not incurred in or caused by the claimed in service event or illness. The examiner explained that the Veteran was seen for recurrent paroxysmal atrial fibrillation, and explained that there was no evidence of chronic atrial fibrillation during service. Rather, the diagnosis was not made until years after her service. The examiner then went on to address a relationship with PTSD, opining it is at least as likely as not that PTSD is a cause of AFIB. The examiner stated there is a causal link, but it has not been scientifically established. A publication was cited that concluded PTSD was associated with increased risk for early incident atrial fibrillation, after adjustment for atrial fibrillation risk factors and depression. The March 2021 opinion provided research that contradicted the October 2016 negative nexus opinion, without providing an adequate explanation or addressing the full medical history in this case. Specifically, the examiner did not address the Veteran's benign heart murmur that was noted on her entrance physical, and whether the noted heart murmur indicates a heart condition that was aggravated by either service or her service-connected PTSD. In light of this, the Board in June 2021 continued to find the medical examinations of record to be inadequate and remanded this matter for an additional opinion. A VA examination was conducted in June 2021, with opinions issued in June and July 2021, wherein the examiner noted diagnoses of atrial fibrillation and cardiomegaly. The examiner opined that the Veteran's heart disorders are less likely than not incurred during her active service, stating that she entered service with a benign heart murmur, which did not cause any problems in the past or at the time of examination. He further opined that her heart disabilities were less likely than not aggravated by her active service because she did not require treatment for heart problems during service. He also opined that the Veteran's heart problem is less likely than not due to her service-connected PTSD, as medical literature is silent for a causal relationship between PTSD and atrial fibrillation. Finally, the examiner provided an indication that there is no conflicting medical evidence of record. However in an October 2021 remand, the Board found the June 2021 VA examination and resulting medical opinions including those rendered in July 2021, were inadequate because the examiner did not respond to all of the Board's requested opinions and provided incomplete or inadequate answers to some questions, and because the theory of obesity as an intermediate step between her PTSD and heart disorders has not yet been explored. The October 2021 Board remand indicated that the examination request sent to the examiner was incomplete as it did not contain all of the questions listed in the Board's June 2021 remand instructions. First, it was noted that the June 2021 VA examiner responded to some of the Board's requests for opinion, but indicated that he was asked the same incomplete question eight times. The examiner therefore did not provide opinions regarding the nature of the Veteran's benign heart murmur. The examiner also failed to provide separate nexus opinions for the separately confirmed diagnoses of Afib and cardiomegaly. Further the examiner did not provide an opinion whether the Veteran's heart disorder was aggravated by her service connected PTSD, instead providing an opinion that it was less likely than not aggravated by active service. Finally, the examiner cited a lack of medical literature as support for his conclusion that the Veteran's PTSD did not cause her heart disorder, and also stated that there was no conflicting medical evidence of record. This failed to address the contradictory evidence cited by the March 2021 examiner, specifically pointing to treatise evidence finding that PTSD is associated with an increased risk of early incident atrial fibrillation. Additionally the October 2021 Board remand noted that no opinion has been provided as to whether the Veteran's obesity served as an intermediate step between her service-connected PTSD and current heart problems, pointing to medical evidence of record suggesting that obesity was contributing to heart problems, and the Veteran's contentions that her obesity was due to taking PTSD medications. In order to address the deficiencies noted in the prior examination reports, a series of VA addendum opinions was obtained in November 2021. The examiner reviewed the evidence in the claims file and provided the following opinions. First, questions regarding whether a preexisting heart murmur was aggravated by service were addressed. In addressing such questions the November 2021 examiner commented on the evidence, which included the Veteran's DD-214 showed active military service from Jun 05, 1991 to Oct 22, 1991. The October 2021 remand letter was reviewed. The evidence reviewed included report of medical history and exam on April 26, 1991 for enlistment documented findings for benign pre-service systolic murmur. Also reviewed were the compensation and pension exam on February 16, 2021 documented a diagnosis for status post ablation of atrial fibrillation and no physical examination findings for murmur, and the VA exam on June 17, 2021 which documented diagnosis for atrial fibrillation and cardiomegaly. The November 2021 examiner was asked to respond to the following questions. (a.) Whether the benign heart murmur noted on entry into service is considered a disease (capable of getting better or worse) or a defect (a static condition). (b.) If considered a disease, whether is it at least as likely as not (a 50 percent or greater probability) that the heart murmur was aggravated beyond its natural progression by her active duty service? If so, whether this aggravation manifested in any currently diagnosed heart problem, including atrial fibrillation and/or cardiomegaly. If aggravation of any currently diagnosed heart problem including atrial fibrillation and/or cardiomegaly was shown the examiner was asked to estimate the baseline level of disability prior to such aggravation. (c.) If the preexisting heart murmur was considered a defect, the examiner was to answer whether the Veteran had any superimposed disabilities due to the heart murmur, to include atrial fibrillation and/or cardiomegaly. If so, the examiner was also asked whether it is at least as likely as not that any superimposed disability was due to an event or illness during active duty service. The examiner was reminded that "defects" are usually static in nature and generally not subject to episodic improvement or worsening, whereas "diseases" are. In responding to these matters, to include addressing conflicting evidence, the examiner confirmed that the claimed condition, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond natural progression by an inservice injury, event, or illness. The rationale cited the reviewed evidence cited above. The examiner then explained that a heart murmur is an extra sound heard when a doctor listens with a stethoscope. This extra sound is created by turbulent blood flow. A heart murmur in children caused by turbulent blood flow can be either normal or abnormal: In normal heart murmurs, the flow can be heard pumping through the heart normally. The examiner stated that the Veteran's benign heart murmur is considered a benign defect (a static condition). The examiner then explained that the heart murmur is a benign condition and does not negatively impact atrial fibrillation and/or cardiomegaly. This opinion was unchanged after reviewing conflicting medical evidence. The November 2021 VA examiner also addressed the etiology of service connection for a heart disorder on a direct basis. In addressing such questions the November 2021 examiner commented on the evidence, which included the Veteran's DD-214 showed active military service from Jun 05, 1991 to Oct 22, 1991. The October 2021 remand letter was reviewed. The evidence reviewed included report of medical history and examination on April 26, 1991 for enlistment documented findings for benign pre-service systolic murmur. Also reviewed were the compensation and pension examination on February 16, 2021 documented a diagnosis for status post ablation of atrial fibrillation and no physical exam findings for murmur, and the VA examination on June 17, 2021 which documented diagnosis for atrial fibrillation and cardiomegaly. The examiner was asked to respond to the following: (d.) For each diagnosed heart disability, whether it is at least as likely as not that such disability was incurred during, or is otherwise related to, the Veteran's active duty service. The examiner opined that the claimed condition was less likely than not incurred in or caused by the in-service injury, event, or illness. The rationale cited to the reviewed evidence cited above. The examiner noted that medical record review was negative for evidence of atrial fibrillation or cardiomegaly during active military service. It is less likely than not that such atrial fibrillation and cardiomegaly condition was incurred during, or is otherwise related to, the Veteran's active duty service. The November 2021 examiner then addressed whether any diagnosed heart disability, is (e.) at least as likely as not aggravated (any incremental increase in disability) by her service-connected PTSD. If aggravation was found, the examiner was asked to identify the baseline level of disability prior to aggravation. The examiner stated that they were unable to determine a baseline for aggravation, and regardless of baseline the Veteran's condition was not at least as likely as not aggravated beyond natural progression by her service connected PTSD. In the rationale, which cited to the evidence previously noted, the examiner discussed how the medical record review was negative for evidence of atrial fibrillation or cardiomegaly during active military service. The examiner further explained that problems with the heart's structure are the most common cause of atrial fibrillation. Possible causes of atrial fibrillation include coronary artery disease and heart attack. The claimant's PTSD did not negatively impact and cause atrial fibrillation. The examiner stated that it is less likely than not that such atrial fibrillation disability was caused or aggravated by her service-connected PTSD. The examiner also explained that cardiomegaly can be caused by many conditions, including hypertension, coronary artery disease, infections, inherited disorders, and cardiomyopathies. Regarding dilative cardiomyopathy, this type is characterized by a wide, poorly functioning left ventricle, which is the heart's primary pumping chamber. The claimant's PTSD did not negatively impact, and cause cardiomegaly and it is less likely than not that cardiomegaly disability was caused or aggravated by her service-connected PTSD. The November 2021 VA examiner then discussed whether obesity (shown by the medical evidence to be a factor in her heart disorder) was secondary to the Veteran's service connected PTSD. In addressing such questions, the November 2021 examiner commented on the evidence, which included the Veteran's DD 214 showing active military service from June 05, 1991 to October 22, 1991. The October 2021 remand letter was reviewed. The evidence reviewed included report of medical history and examination on April 26, 1991 for enlistment documented findings for benign pre-service systolic murmur. Also reviewed were the compensation and pension examination on February 16, 2021 documented a diagnosis for status post ablation of atrial fibrillation and no physical examination findings for murmur, and the VA examination on June 17, 2021 which documented diagnosis for atrial fibrillation (Afib) and cardiomegaly. Medical record review was negative for evidence of atrial fibrillation or cardiomegaly during active military service. A medical note on October 31, 2014 demonstrated a BMI of 36.58, consistent with obesity. The November 2021 VA examiner was asked to respond to the following: f.) The claims file contained evidence that the Veteran's weight has contributed to her current heart problems, and she has asserted that her weight gain is caused by the medications she takes for her service-connected PTSD , including, but not limited to, olanzapine (Zyprexa), nefazodone (Serzone), and mirtazapine (Remeron). Accordingly, the examiner was also asked to opine as to whether it is at least as likely as not that the Veteran's obesity was caused by her service-connected PTSD , including by medications prescribed to treat it. If the obesity was determined to be a result of the service connected PTSD, the examiner was further asked to respond to whether (g.) such obesity resulting from the PTSD is a substantial factor in causing her current atrial fibrillation and/or cardiomegaly. Additionally, if the obesity was determined to be a result of the service connected PTSD, the examiner was further asked to respond to whether (h.) it at least as likely as not that her atrial fibrillation and/or cardiomegaly would not have occurred but for the obesity caused by her service-connected posttraumatic stress disorder. The examiner gave an opinion in response to these questions (f.) through (h.) pertaining to obesity, stating that the claimed obesity (contributing to her heart condition) is less likely than not due to or the result of her PTSD, with the above reviewed evidence cited in the rationale. The examiner went on to explain that the most common causes of obesity are overeating and physical inactivity. Ultimately, body weight is the result of genetics, metabolism, environment, behavior, and culture. Physical inactivity was also a cause. Sedentary people burn fewer calories than people who are active. Although obesity can be associated with oral medication treatment of PTSD, medical record review did not reveal consistent clinical evidence for oral medication treatment of PTSD to negatively impact and proximately cause obesity condition. It was less likely than not that the Veteran's obesity was caused by her service-connected PTSD, including by medications prescribed for PTSD. Having reviewed the record, the Board finds that the evidence is against a grant of service connection for any diagnosed heart disorder, to include the atrial fibrillation, status post ablation, and cardiomegaly on any basis. In this matter the Board finds the most probative evidence to be the unfavorable opinions from the November 2021 VA examiner, who after review of the evidence in the claims file, addressed the multiple questions provided by the Board in the prior remands, and provided adequate rationale for the opinions. To the extent that the November 2021 VA examiner did not explicitly address favorable evidence, the examiner nonetheless provided sound medical explanations to support the unfavorable opinions. Although the Veteran underwent multiple examinations prior to November 2021, the rationales for the opinions were found to be inadequate in prior Board remands as discussed in detail above. This includes the February 2021 VA examiner's favorable opinion citing a relationship between Afib and PTSD, finding it is at least as likely as not that PTSD is a cause of AFIB. This opinion has been found to be lacking in adequate rationale and prompted the Board to request additional opinion. Thus the opinion lacks probative value. First, regarding whether there was a preexisting heart disorder aggravated by service, the Board notes that the presumption of soundness does not apply in this instance because the heart murmur was noted on the April 26, 1991 examination prior to service. The Board finds most probative the opinion from the November 2021 VA examiner who determined that that the Veteran's benign heart murmur is considered a benign defect (a static condition), and that there was no superimposed disability, nor was there any aggravation of this disability, again explaining that this was a static defect and not a disability. Additionally the November 2021 VA examiner then explained that the heart murmur is a benign condition and does not negatively impact atrial fibrillation and/or cardiomegaly. The Board does not find there to be probative evidence of record to adequately rebut this opinion. Thus the Board finds that a preexisting benign heart murmur to be a preexisting defect for which service connection is not warranted. See 38 C.F.R. §§ 3.303 (c), 4.9. The Board notes that a diagnosis of valvular heart disease was made in the October 2016 VA examination. However, subsequent VA examinations including the November 2021 VA examination, did not give this diagnosis, nor did the treatment records. Thus the Board finds the more appropriate diagnoses are shown to be the atrial fibrillation (Afib) and the cardiomegaly diagnosed in the subsequent VA examinations and treatment records. The Board finds that the evidence is against a grant of service connection on a direct basis for the diagnosed disorders of Afib status post ablation, or for cardiomegaly, which were diagnosed in the prior VA examinations and the VA and private treatment records, which addressed recurrent Afib episodes. Again, the November 2021 VA examiner gave an opinion with adequate rationale that it is less likely than not that such atrial fibrillation and cardiomegaly condition was incurred during, or is otherwise related to, the Veteran's active duty service. None of the other records or examination reports are shown to contradict this opinion. Thus the Board finds that service connection for a heart disability, to include Afib or cardiomegaly is not warranted on a direct basis. As for whether a heart disability, to include Afib status post ablation, or cardiomegaly is due to or aggravated by the service connected PTSD to include medications to treat the PTSD, the evidence is against such a grant. The opinion from the November 2021 VA examiner provided explanations with adequate rationale finding that the PTSD and the medications used to treat the PTSD did not cause or aggravate these heart disorders. Furthermore, the November 2021 VA examiner also gave opinions accompanied by adequate rationale, which determined that the Veteran's obesity was not due to or aggravated by PTSD including the medications used to treat the PTSD. Thus although the evidence does show that the Veteran's obesity issues were shown by medical evidence to have an unfavorable impact on her heart, the preponderance of the medical evidence does not show the obesity was due to or aggravated by the service connected PTSD including medications for PTSD. The Board acknowledges that there is medical evidence showing multiple episodes of Afib repeatedly converted to normal following medical treatment, with these incidents precipitated by the Veteran having anxiety or panic attacks, including those triggered by recurrent thoughts of her PTSD stressors. However none of these records indicated that the episodes of Afib were made permanently worse by her PTSD. As previously discussed, the February 2021 VA examiner's favorable opinion citing a relationship between Afib and PTSD was found to lack adequate rationale and thus lacks probative value. The Board concludes that, while the Veteran has a current heart disability of Afib status post ablation and cardiomyopathy, in light of Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018), the evidence of record persuasively weighs against finding that the Veteran's heart disability of Afib status post ablation and cardiomyopathy were incurred or aggravated in service or are otherwise proximately due to or the result of, or aggravated beyond its natural progression by service-connected disability. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). As discussed at length the November 2021 VA examiner has provided unfavorable opinions regarding the etiology of the heart disorder including discussion of the preexisting heart murmur, and on a direct and secondary basis. As previously discussed, all opinions from the November 2021 VA examiner are accompanied by adequate rationale and outweighs the conflicting medical opinions. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008), Barr v. Nicholson, 21 Vet. App. 303 (2007), Stefl v. Nicholson, 21 Vet. App. 120 (2007), Prejean v. West, 13 Vet. App. 444 (2000). The Veteran believes her heart disorder is either directly related to service or proximately due to or the result of/aggravated beyond its natural progression by her PTSD. The Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body. Therefore, it is outside the competence of the Veteran in this case because the record does not show that she has the skills or medical training to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board finds that the evidence is against a grant of service connection for a heart disorder. Eric S. Leboff Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Eckart 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.