RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03666
BRANCH OF SERVICE: AIR FORCE	SEPARATION DATE:  20080722

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Air National Guard E3, Vehicle and Vehicular Equipment Maintenance Helper, medically separated for “neurogenic syncope…,” with a disability rating of 10%.

CI CONTENTION:  The CI’s conditions continue to worsen and negatively affect daily activities.  Her complete submission is at Exhibit A.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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 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 based on 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:  

SERVICE PEB - 20080611	VARD - 20100924	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Neurogenic Syncope with Ventricular Asystole …	7018	10%	Syncope With Ventricular Asystole	7018	NSC	20100830	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS: NA	

ANALYSIS SUMMARY:  

Neurogenic Syncope with Ventricular Asystole.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI experienced syncopal (loss of consciousness from insufficient blood flow to the brain) episodes approximately 20 months prior to referral for MEB.  While being transported in a car following a stressful commercial aircraft flight, the CI developed severe dizziness, passed out, and shortly thereafter vomited.  She was unconscious for only a few seconds, regained consciousness immediately, and was alert.  There was no bowel or bladder incontinence or seizure-like activity.  The CI may have struck her head, but she did not sustain other injuries.  
While being transported by paramedics to the emergency room (ER), the CI had another syncopal episode.  After arrival at the ER, she had a recurrent syncopal episode with asystole (cardiac arrest) and an approximately 10-second pause in heart rate.  The CI had transient loss of consciousness for just a few seconds and regained consciousness.  She reported a history of a similar occurrence approximately 5 years prior.  She reported a syncopal episode with loss of consciousness while under the stress of chasing a horse.  The assessment listed syncope.  The examining cardiologist documented, “The patient has recurrent syncopal episodes, which appear to be secondary to transient severe bradycardia [slow heart rate].  This may be secondary to underlying sick sinus syndrome [(SSS) sinoatrial (SA) node pacemaker cell dysfunction causing inappropriate bradycardia, sinus pauses, and arrest] but, given the history, is more suggestive of severe vasodepressor syncope [neurocardiogenic syncope with exaggerated physiologic reflex causing vasodilatation and/or bradycardia leading to systemic hypotension, cerebral hypoperfusion, and transient loss of consciousness], causing severe bradycardia.  The patient's prior history of a syncopal episode during a stressful situation is consistent with this diagnosis.”  A transthoracic echocardiogram (TTE) was normal except for mild mitral valve thickening and trace tricuspid valve regurgitation.  On 12 April 2006 the CI underwent insertion of a temporary transvenous pacemaker for severe bradycardia, sinus pauses (up to 10-seconds), and recurrent syncope.  This was followed by implantation of a permanent dual-chamber pacemaker with a right atrium and right ventricle lead (electrode).  Chest diagnostic imaging (X-ray) showed excellent position of her atrial electrode in the right atrial appendage.  A repeat TTE was normal except for a pacemaker lead in the right ventricle and a mildly dilated right atrium.  A cardiology encounter confirmed that while her pacemaker pulse generator functioned normally, there was a malfunction of the ventricular electrode compatible with a micro-displacement.  The cardiologist opined that it was medically necessary to urgently correct this situation.  On 29 January 2007 the CI underwent a pacemaker revision with explant of the original ventricular lead and implant of a new ventricular lead.  A cardiology follow-up documented, “She has been quite active and started jogging again.  From a cardiac standpoint, she is doing quite well and essentially asymptomatic, specifically, she has not had any syncope, presyncope or palpitations.”  A cardiology consultation documented that the CI had a history of neurocardiogenic syncope with malignant ventricular asystole and recurrent syncopal episodes treated with permanent pacemaker implantation.  The cardiologist documented “… from a medical standpoint she did have serious ventricular asystole that was life threatening and will require lifelong backup pacemaker. … She does have limitations of activity in that she cannot get near very high radiofrequency energy emitting devices.  She knows to stay away from auto or truck engines that have high frequency RS [RF] energy.  She needs certainly to stay away from occupational things such as arc welding. … There is some activity restriction that is outlined above but not limited just to this.  She will require long-term cardiology follow-up and will need future operative procedures for battery changes and could possibly require additional surgery depending upon the long-term integrity and function of her leads.”  The 25 January 2008 NARSUM, 7 months before separation, recounted the history and interventions. The NARSUM noted that since permanent pacemaker implantation, the CI had had no subsequent syncopal episodes, but that “She now states that she feels great and is asymptomatic.  She works 5-6 days/week without difficulty.”  The CI denied syncope, dizziness, chest pain, dyspnea (shortness of breath), or palpitations.  She exercised on a treadmill for 1 hour two to three times per week and walked/jogged with a dog daily for 20 minutes.  Her medication was an oral contraceptive pill.  The diagnosis listed neurogenic syncope with ventricular asystole, status post pacemaker implantation and wire replacement, now stable.  The 30 August 2010 VA Compensation and Pension (C&P) examination, 4 years after separation, recounted the history and interventions.  The CI complained of periodic lightheadedness (about once per month) lasting a few minutes up to a whole day.  The CI denied syncope, chest pain, dyspnea, palpitations, or fatigue.  The symptoms had no effect on her job/occupation (retail at pool store) or activities of daily living.  Her response to pacemaker implantation was good and her clinical course since onset had improved and been stable for the past few years.  Continuous medication was not required for control of her condition.  A chest X-ray showed a cardiac pacemaker generator with atrial and ventricular wires.  
An electrocardiogram was interpreted by a cardiologist as showing an electronic atrial pacemaker, a nonspecific intraventricular conduction delay, and a sinus rhythm.  Estimated metabolic equivalents (resting metabolic rate used to describe functional capacity or exercise tolerance) was at least 10 by Veterans Specific Activity Questionnaire (a self-administered symptom questionnaire to estimate a patient’s exercise capacity and other criteria).  The diagnosis listed neurogenic syncope with ventricular asystole requiring a pacemaker implantation and wire replacement.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 7018 code (implantable cardiac pacemakers) citing “neurogenic syncope with ventricular asystole requiring pacemaker implantation and wire replacement, existed prior to service (EPTS), with permanent service aggravation.”  The VA did not service connect under the 7018 code based on the VA C&P examination, and the C&P examination clarification, 4 years after separation.  The VA documented, “Since you only served in a capacity of active duty for training while you were in the Air National Guard and you are not currently entitled to service connection for a disability that incurred during this period, your active duty for training is not considered active service, and presumption of soundness does not apply.” Also noted was, “There is no evidence that the condition permanently worsened as a result of service.”  Recognizing the remote temporal relationship to time of separation, the Board assigned little probative value to the VA C&P examination.  The implanted pacemaker successfully treated the neurocardiogenic syncope, bradycardia, and ventricular asystole.  The CI denied syncope, dizziness, or dyspnea and required no continuous medication use.  There were no supraventricular (SVT, tachycardia) arrhythmias (7010), ventricular (sustained) arrhythmias (7011), or atrioventricular blocks (7015) for consideration under the respective codes.  While there was an implantable cardiac pacemaker (7018), it was not less than 2 months since implantation or reimplantation, consistent with the 100% rating.  Being greater than 2 months since implantation or reimplantation of implantable cardiac pacemaker (7018) was consistent with the 10% rating under the respective code.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the syncope with ventricular asystole condition.  

BOARD FINDINGS:  In the matter of the syncope with ventricular asystole condition and IAW VASRD §4.104, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140710, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MR

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-03666.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

Attachment:
Record of Proceedings