RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00345
BRANCH OF SERVICE:  Army	
DATE OF PLACEMENT ONTO TDRL:  20051229
DATE OF REMOVAL FROM TDRL:  20070814

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (92A30/Automated Logistical) medically separated for cardiac condition.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards. He was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB).  The “left ventricular noncompaction syndrome,” and “IgA Nephropathy (chronic glomerulonephritis) w/secondary microhematuria,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “left ventricular non-compaction syndrome, with extensive trabeculations throughout the left ventricular myocardial walls” as unfitting, rated 30%, citing application of AR 635-40.  The remaining condition was determined to be not unfitting.  The CI made no appeals and was placed on Temporary Disability Retired List (TDRL).  Approximately 19 months later, the IPEB adjudicated the heart condition as unfitting, rated 10%.  The CI made no appeals and was medically separated.  

CI CONTENTION:  The VA assigned higher ratings for the conditions that resulted in his unfitness for duty.  His complete submission is at Exhibit A.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation. 

RATING COMPARISON: 

Final PEB – 20070814	VA Rating Decision1 – 20060915	
TDRL Placement – 20051229	Code	Rating	Condition	Code	Rating
Proximate	
Condition		TDRL
Placement	TDRL Removal			TDRL2
Placement	TDRL2 Removal	
Cardiomyopathy	7020	30%	10%	Left Ventricular Noncompaction Syndrome	7099-7011	30%	30%	
Other x 1 (Not in Scope)	Other x 5 (Not in Scope)	
RATING:  30% → 10%	RATING:  50% 	
1. Most proximate to TDRL Placement
2. Rating derived from C&P exam dated 20060822, ~8 mos. post-TDRL placement 

ANALYSIS SUMMARY:  

Cardiomyopathy Condition.  The service treatment record (STR) in a note dated 7 December 2004 indicated the CI had an episode of intraoperative hypotension and desaturation (a low oxygen level) during surgery for fibroids.  Cardiology workup of the heart revealed mid/distal anterior hypokinesis (abnormally diminished muscular function or mobility) with a qualitative perfusion scan suggesting reversibility.  A transesophageal echocardiogram showed a small ASD (atrial septal defect)/PFO (patent foramen ovale) and a cardiac MRI showed multiple trabeculae (protrusions) in the left ventricular apex.  The diagnosis of a myocardial non-compaction syndrome (an unclassified cardiomyopathy thought to be caused by embryogenesis arrest of the endocardium and myocardium with a uniformly poor long term prognosis) was made.  The CI was treated with the beta blocker Coreg (carvedilol), ramipril (an ACE inhibitor), and lovenox (an anticoagulant) with a plan to introduce Coumadin (warfarin, an anticoagulant).  However, the CI chose not to take the Coumadin and was instead placed on an enteric coated aspirin (ECASA) and the Coreg was changed to Lopressor (metoprolol, a beta blocker) in January 2005; and the ramipril dose was increased in March 2005.  A genetic study, G4.5 mutation analysis, neither confirmed nor ruled-out a mutation in the G4.5 gene, which is associated with left ventricular non-compaction.  The CI indicated she was still having intermittent “tightness” and chest pain on the right side at rest without exertion, although she was able to do the elliptical trainer and treadmill at 2.5 mph.  A stress test performed in April 2005 was equivocal with an abnormal resting EKG with T wave inversions and non-specific T wave changes; however, there were no changes during the stress test when she achieved an exercise capacity of 11.70 METs.  In June 2005 a SPECT scan (a nuclear imaging study) showed no evidence of myocardial ischemia (lack of blood flow) or infarction (heart muscle tissue death).  The CI had a normal coronary angiogram and a repeat stress test in August 2006 was associated with some ST changes at rest and during exercise in the absence of chest pain or shortness of breath.  As a result she was not pushed to obtain her maximum predicted heart rate and she achieved 5-6 METs after 3 minutes 39 seconds.  A post-separation TDRL removal note dated 13 August 2007 indicated the CI had another stress test with T wave inversions at V5-V6 and an exercise capacity of 10.50 METs at 9 minutes 17 seconds.  

At the MEB examination dated 16 May 2005, the CI reported on DD Form 2807-1 shortness of breath while being active, going up many flights of stairs, and sometimes during household chores.  She also had pain and pressure in the chest when being very active, at rest, and during vigorous exercising.  She additionally noted the heart trouble diagnosis was non-compaction of the left ventricle.   The MEB physical examiner noted on DD Form 2808 a regular rate and rhythm (RRR) of the heart and listed the left ventricular non-compaction syndrome in the summary of defects and diagnoses section.  The commander’s statement dated 12 August 2005 indicated that due to the CI’s physical condition, she was limited in her physical capabilities to adequately and completely perform tasks of frequent or constant lifting in excess of 50 pounds and she had not completed a physical fitness test since 2001.

The MEB narrative summary (NARSUM) dated 1 September 2005 noted the CI complained of occasional fatigue, sometimes too severe to exercise as well as occasional intermittent dyspnea (shortness of breath) on exertion with running and intermittent episodes of right upper chest pain.  On examination her blood pressure was 109/63 with a heart rate of 66 and respiratory rate of 12.  Examination of the neck veins and carotid arteries was normal; the chest was clear; the heart was normal with a regular rate and rhythm and with a normal S1-2 without a gallop, murmur or rub; and the extremities did not demonstrate clubbing, cyanosis (purplish color due to low blood flow or low oxygen) or edema.  The examiner opined the CI was a subjective functional therapeutic Class II, although she was a therapeutic Class I on the treadmill.  Additionally, she was at risk for significant cardiac morbidity including congestive heart failure, left thromboembolic events and arrhythmias.  A permanent P3 profile was issued in November 2005 for left ventricular non-compaction syndrome with limitations of all functional military activities except wearing a protective mask and all chemical defense equipment, no physical fitness or training, and no deployment where definitive medical care was not immediately available.   

At the VA Compensation and Pension (C&P) examination dated 11 April 2006, performed 8 months after separation, the CI reported her medical history related to the diagnosis and treatment of the left ventricular non-compaction syndrome, while the examiner referenced the echocardiogram done in February 2006, which was interpreted as demonstrating an increased left ventricular wall thickness in the apical portion of the lateral anterolateral wall with trabeculations in both the right and left ventricles.  On examination the CI had no distended neck veins or carotid artery bruits (abnormal sound caused by turbulent flow).  There was no chest wall tenderness and the lungs were clear.  The heart had a sinus rhythm and the PMI (point of maximum impulse) was in the normal location.  There were no shocks, thrills, friction rubs, or gallops.  A grade 1/6 soft systolic murmur was heard near the apex with no radiation and the extremities were symmetrical without cyanosis of the nail beds, clubbing, or edema. The CI had a borderline ejection fraction of 51%, while the examiner’s estimate was 6 METs based on her symptoms.  The VA Rating Decision (VARD) indicated at an examination dated 5 September 2006, which was not available for review, the METs estimate was 5-6.   

The Board directed its attention to its rating recommendation based on the above evidence. The PEB assigned a 30% rating on TDRL placement using code 7020 (Cardiomyopathy) for the left ventricular non-compaction syndrome and noted the “extensive trabeculations are considered to be equivalent to hypertrophy.”  The VA assigned a 30% rating using code 7099-7011 (Ventricular arrhythmias (sustained)) for the left ventricular non-compaction syndrome.  At the TDRL removal the PEB assigned a 10% rating using code 7020 for cardiomyopathy based on the CI’s having achieved 10.50 METs on exercise testing in August 2008 along with continuous required medication.  The Board members agreed that the 30% rating on TDRL placement was appropriate as long as the premise that the ventricular trabeculations are considered to be equivalent to hypertrophy; however, the CI achieved 11.7 METs in April 2005, more than 8 months prior to separation, while more proximate to separation on a modified and shortened stress test in August 2005, she achieved 5-6 METs.  The VA examiner estimated the number of METs to be 6 in April 2006.  The Board discussed the ramifications of the disparities of the different METs results.  To achieve a 30% rating using code 7020 there must be a “Workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina (chest pain), dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray.”  The Board discussed the probative value of the different METs whether as a result of a full or partial stress test versus an estimate, which is permitted under the VASRD §4.104 Note (2) as well the probative value of the trabeculations related to hypertrophy.  Increased ventricular wall thickness was noted on an echocardiogram in February 2006, 3 months post-separation, thereby supporting hypertrophy without having to specifically use the ventricular trabeculations as a measure of hypertrophy.  Therefore, the 30% rating for TDRL placement is reasonable based on ventricular hypertrophy.  A post-separation TDRL examination indicated 10.50 METs, which parallels a prior complete stress test and was not significantly disparate from April 2005 at which time the CI achieved 11.7 METs.  However, the same issue in regard to hypertrophy was discussed, although there was not an additional echocardiogram proximate to TDRL removal to provide unequivocal evidence of hypertrophy nor was there an EKG or chest X-ray that demonstrated hypertrophy.  However, the trabeculations remained and it is not unreasonable, to expect the ventricular wall thickening to have persisted rather than to have improved.  Therefore, the Board considered the cardiac hypertrophy to have existed at the time of TDRL removal, which rates 30% despite the 10.5 METs that exceed the 7 METs that warrant 30%, while aware of the VA examiner’s estimate of 6 METs in April 2006 and 5-6 METS in September 2006.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 30% for the cardiomyopathy condition on TDRL placement and a disability rating of 30% on TDRL removal.  

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.  As discussed above, PEB reliance on AR 635-40 for rating cardiomyopathy was operant in this case and the condition was adjudicated independently of that regulation by this Board.  In the matter of the cardiomyopathy condition, the Board unanimously recommends no change to the disability rating of 30% at TDRL placement and a disability rating of 30%, coded 7020 IAW VASRD §4.100 on TDRL removal.  There were no other conditions within the Board’s scope of review for consideration.  

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of her prior medical separation:  

CONDITION	VASRD CODE	RATING	
		PERMANENT	
Cardiomyopathy	7020	30%	
RATING	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 2013w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB																		

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation 
for XXXXXXXXXXXXXXXXXXXXX, AR20160000439 (PD201400345)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to recharacterize the individual’s separation as a permanent disability retirement with the combined disability rating of 30% effective the date of the individual’s original medical separation for disability with severance pay.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum:

	a.  Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.

	b.  Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 30% effective the date of the original medical separation for disability with severance pay.

	d.  Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY:

			      
						      					
Enclosure
					
CF: 
(  ) DoD PDBR
(  ) DVA