Recent cardiac surgery--likely outcomes??? MEB/PEB back in 2004

jtludwig

PEB Forum Regular Member
Good evening,

So here is my situation. I'm looking for what everyone thinks the likely outcomes will be. Thanks!

I have a congenital Bicuspid Aortic valve and aortic root aneurysm that was recently operated on (1 Feb 2010). I now have a mechanical aortic valve and part of my aortic root was replaced. I will require lifetime Coumadin/Warfarin therapy.

In June 2003 I was commissioned a 2LT in the Air Force. In Jan 2004 at a routine physical, my Air Force doctor says to me "How'd you ever get in the Air Force? I'm sending you to an MEB for your Bicuspid valve!". I went thru the entire MEB/PEB process (medical discharge, existed prior to service, 10% disability, 0 severance was the answer I kept getting), and ended up doing the final appeal to the Secretary of the Air Force where I was returned to duty with an assignment limitation code that basically restricted me to stateside duties. This was all concluded by Dec 2004.

Now fast forward 6 1/2 years or so. On Feb 1 2010 I had the aortic valve replaced with a mechanical valve and part of my aortic root replaced. Since the valve is mechanical, I will require lifetime coumadin/warfarin therapy. I am still on convalescent leave but the MEB office at my base (Hanscom AFB) has started the RILO process (Review in lieu of I believe is what it means). They have told me that the outcome of the RILO could be a requirement to do an MEB/PEB. I asked what they thought the likely outcomes would be but they said they had no idea. Does anyone have any idea what is going to happen?

Will the RILO just return me to duty since I am expected to have no physical restrictions once I heal and already have an assignment limitation code? The idea with this approach is that nothing has really changed in what I can or cannot do or where I can or cannot go, and when you think about it, I am actually "healthier" now than I was before.

I have 6 1/2 years of service and am now a Captain. If I have to do an MEB/PEB, what is the likely outcome? Some sort of medical discharge? If I am discharged will I receive severance pay or anything like that, keeping in mind that this is a condition that I was born with? I don't know if it is considered to have been aggravated by my military service or not.

Also..I am an acquisition officer/program manager so I work in an office. No crazy field exercises or anything like that.

Thanks for the insight everyone!

--Jason
 
Jason,

I would need more details to know whether you are looking at fit or not fit (sounds like it could be fit, but would need to know doctor's/commander's input and recommendations).

I would say that it should be compensable and be found to be at least service aggravated. I do not see how, if they said this condition was EPTS, that they could show it to be natural progression. (Conditions are presumed incurred while on duty, if that is overcome, it is still presumed service aggravated unless they can show, by citation to generally accepted medical principles, that the condition would be the same whether you were in the military or not).

You are just up the road, at Hanscom. I used to go there when I was in the MA Army Guard, so I know your neck of the woods.
 
Jason (the original poster),

While I'm sorry to hear of your condition, it is exciting to finally meet someone else with this disorder. Less than 1% of the population has this congenital defect..I figured it would be highly unlikely for me to ever meet anyone in regular society, as opposed to a military member, who suffered from a bicuspid valve. I was medically retired (TDRL 60%) back in June 2009 for Valvular Heart Disease (namely bicuspid aortic valve). The rating criteria can account for several factors (METS rating, ejection fraction, etcetera). I'm currently under observation...and probably will be for the next 30 years as my cardiologist does not want to replace my valve and put me on coumadin at such a young age (I'm in my mid-20's).

The key factor in my case was the ejection fraction and showing of symptoms. While obviously I was born with this condition, it did not become symptomatic until after a deployment to Iraq. This correlation was highlighted in my edited NARSUM after the PEB informally returned the case asking for me to show how it was not EPTS/natural progression (which, as Jason the forum administrator stated is their burden, not mine). My ejection fraction was right at the 49/50% mark, meeting the criteria for a 60% rating.

I'm assuming that prior to your valve replacement surgery, you were suffering from stenosis/regurgitation/and all the symptoms resulting. I'm also assuming that throughout your first few years in the military, you showed no symptoms. Your condition EPTS but was aggravated by service. Unless you were showing symptoms prior to joining the military, I don't think there is much in terms of reasoning or evidence the PEB can substantiate a natural progression argument with. It is a generally accepted medical principle that stress and certain types of physical exertion place an acute stress on a bicuspid aortic valve. We all know that the military can be an extremely stressful occupation (especially while deployed) and requires high levels of physical exertion. If you can provide cause and effect type evidence (i.e. x number of years of PT caused symptoms to become gradually worse) your condition being classified as aggravated by service is very probable (in light of my experience with the same disorder).

My advice is just based on assumptions. As Jason stated, more facts of the case would help in estimating what will result from a MEB/PEB. Have you undergone any stress tests/echos/TEEs since the surgery? The data from these tests could be helpful. Are you trying to stay in the AF?

As an aside, how are you feeling? I will inevitably be a recipient of a mechanical heart valve sometime within the next 2 or 3 decades and am curious. How is the medication affecting you? I hope your recovery goes well and please feel free to ask any questions you may have.
 
Good morning Jason/carnelli53,

In terms of if I'm looking for a fit/not fit decision--I would like to stay in the Air Force if possible, however I am much more confident of my ability to find a good/meaningful job at either a company or in the civil service now than I was when I was a 2LT with less than a year of service and going thru a MEB, so I'm not going to freak out if it doesn't go my way...though I would be very disappointed.

In terms of doctor's/commander's input and recommendations--I'm not sure yet how that is going to play out...I'm still on convalescent leave for a few more weeks so I haven't even been back in the office yet to pursue those things. I haven't had any follow up echos/stress tests yet but am scheduled for these in the next week or two (they are a prerequisite for the cardiac rehab program which is basically a supervised exercise program).

Carnelli53,

What has been kind of strange about this whole bicuspid valve thing, is yes while I did have some pretty good regurgitation (moderate) and a bit of stenosis, I've never considered myself to have any symptoms. The heart docs tell me though that I probably wasn't realizing the changes that were occurring since they were so gradual (diminished excercise capacity, etc). I certainly didn't have any symptoms before then and have only been on physical restrictions for the past 3-4 months while I was getting this straightened out. What drove the need to have the surgery now instead of 6 years ago or in the future was that my ejection fraction was getting a little low and it looked like the leakage of blood back into the heart was starting to strain it a bit.

Like I said..the surgery was on 1 Feb. I feel better than I thought I would at this point (still a bit sore though from the incision) and while I haven't started jogging/running yet (that will happen under supervision at the cardiac rehab program that I start in a few weeks) I have started walking several miles a day and feel fine. I'm fortunate that I live in Boston which has such great medical centers--I had my surgery at a hospital that people travel from around the world for and it's right down the street! Also..Tricare has been great (I was a bit concerned about this)...so I have been pretty happy with how the Military has handled things up to this point.

I was concerned about how much of hassle the Coumadin would be, but it has actually been pretty easy. The clinic and I were able to figure out the appropriate dose pretty quick so I just check my blood perioducally with a finger prick. I was also told that several Coumadin replacements are in the pipeline (next 5-10 years) that should make the whole process much more predictable and less burdensome. Tricare has given me a home Coumadin monitor (about $2500 to buy one on your own) so I don't even have to go to the clinic anymore...I just email the nurse with the results and she adjusts my dose.

Anyways..thanks for the great responses! It will be interesting to see how this plays out.

--Jason
 
Im Air Force as well and I know after my surgery I was seen by a Army Cardiologist and I asked him what are the usual out comes of the MEB for a valve replacement and he told me that once you have a valve installed your going to get discharged... now this is coming from a Army Cardiologist so maybe the Air Force is different but he was saying you have to be near a Cardiologist and so many things need to be put in place that they just Med board you out. I know a couple weeks after my 2nd heart surgery (yeah I've had 2 since the MEB started) I started to get chest pains that weren't normal and went to the Army hospital in Germany and once they heard I had the surgeries and was having chest pains the whole hospital went into panic mode... everything turned to be alright but I saw the Cardiologist at the end and he was just like see what I was talking about.
 
Just a quick update..did a stress test recently and was told I achieved 11Mets. I was also told that my ejection fraction (according to echocardiogram) was 45% but that it may increase in the future. Seems like I would have a case for at least TDRL (since ejection fraction may possibly go over the 50% threshold sometime in the future). What do you think? Also...does the aortic root aneurysm that I had to have replaced with a dacron graft have any effect on my rating? How about lifetime coumadin use? Any impact there?

Only thing I'm concerned with is that the board may say that since I had the bicuspid valve since birth that it existed prior to service and was not aggravated by service. Seems to me though that would be a hard case for them to make, especially with the aortic aneurysm that I've had develop over the past 2-3 years (I have 7 years of service).

When I go sign the NARSUM next week, I intend to make sure that it references the low ejection fraction and aneurysm. Anything else I should look out for? It's still my opinion though that I should be returned to duty with the same assignment limitation code that I had from my last MEB back in 2004. Only thing I want to watch out there though I think is that if I were returned to duty, and then had problems down the road with my physical fitness tests or something (due to this condition), that they didn't try and administratively seperate me with no benefits.


Thanks!
 
Im signing mine next week too. My Doctor pretty much said to return to duty which is pretty slim that they would give me and I guess us a lifetime walking waiver if thats what your talking about for the PT part. So if they keep you in and dont offer that you should ask for it if you want it. He also gave a heads up for if they keep me in during the push up part that when your testing it your probably going to remember you had the surgery with the aches your going to get. I'm opting to get out after 7 years. I have to get a 3rd surgery down the road and who knows how many after that but plan on having a doctor I feel comfortable with doing it. The part that sucks is not knowing what % they are willing to give and the waiting which is looking like the whole MEB process is going to take a year
 
jtludwig,

Since you're trying to stay in, I hope the PEB works with you and allows you to return to duty. In the case that they find you unfit for duty, you should receive a 60% rating (more than likely TDRL, due to the changing nature of the EF as your cardiologist noted) based on your ejection fraction of 45% - this is for the valve replacement. 60% affords you retirement, TRICARE benefits, a monthly pension (60% of your high-3), and more.

Lifetime coumadin requirement is most likely going to be classified as secondary to the valve replacement, I'm guessing that a separate rating of your lifetime coumadin use would be considered pyramiding under scrutiny (which is against the rules). Something to note however, under the valve replacement VA code continuous medication is grounds for a 10% rating - so it looks like that would be the minimum you would be looking at down the road. As stated in previous posts, there has been discussion on the coumadin use rating issue - a search of previous posts could bring some light to this question.

I would not worry too much about the EPTS issue. I know it is probably unavoidable in the anxiety that one experiences prior to their case going to the PEB (I actually asked the same question when my case was pending). The military would have to cite accepted medical principles and published medical material that states your condition, regardless of the acute stress and unique exertion required of military service, would have progressed the same had you never served in the military. From what I understand, such medical principles and published material do not exist for valvular heart disease. Even if such material does exist, it probably does not meet the burden of proof that is required of the PEB to show that a given condition EPTS and would not have progressed any differently in the case a member never served.

If it is of any help, my NARSUM stated simply that while a bicuspid valve is a congenital condition I had no symptoms or any signs of regurgitation/stenosis/murmur prior to entering active duty. It also stated that I completed my initial military training without symptoms and without incident, it was not until a deployment to Iraq that I began showing symptoms that precipitated an investigation into my heart function. I think this chronological explanation of symptoms (and/or lack thereof) painted a very simple picture for the PEB to evaluate. Your case in similar insofar as you did not have any serious symptoms until well into your service. Try not to worry about the EPTS issue!

If you are found fit for duty and your condition becomes worse down the road (unable to perform PT, etc) it is possible that your command may try to administratively separate you, but keep in mind that this course of action is not correct nor is it legal (and if it does occur, it is most likely grounds for an appeal ex post facto). With your condition becoming worse, you should simply be processed through another MEB/PEB. Hopefully you never have to cross that bridge, but if you do come to it, the regulations and law are on your side.

Good luck with the rest of the process and be sure to keep us updated.

carr23,

Cardiac ratings - as stated earlier in this thread - are contingent on the results of stress tests, EKGs, echos, TEEs or any combination thereof. Once you have some baseline numbers, refer to VA code 7000 for valvular heart disease and check out the rating criteria. You will note that the METS rating (from a stress test) and the ejection fraction (from a nuclear stress test, echo, or TEE) are the important numbers for rating purposes.
 
jtludwig,

Since you're trying to stay in, I hope the PEB works with you and allows you to return to duty. In the case that they find you unfit for duty, you should receive a 60% rating (more than likely TDRL, due to the changing nature of the EF as your cardiologist noted) based on your ejection fraction of 45% - this is for the valve replacement. 60% affords you retirement, TRICARE benefits, a monthly pension (60% of your high-3), and more.

Lifetime coumadin requirement is most likely going to be classified as secondary to the valve replacement, I'm guessing that a separate rating of your lifetime coumadin use would be considered pyramiding under scrutiny (which is against the rules). Something to note however, under the valve replacement VA code continuous medication is grounds for a 10% rating - so it looks like that would be the minimum you would be looking at down the road. As stated in previous posts, there has been discussion on the coumadin use rating issue - a search of previous posts could bring some light to this question.

I would not worry too much about the EPTS issue. I know it is probably unavoidable in the anxiety that one experiences prior to their case going to the PEB (I actually asked the same question when my case was pending). The military would have to cite accepted medical principles and published medical material that states your condition, regardless of the acute stress and unique exertion required of military service, would have progressed the same had you never served in the military. From what I understand, such medical principles and published material do not exist for valvular heart disease. Even if such material does exist, it probably does not meet the burden of proof that is required of the PEB to show that a given condition EPTS and would not have progressed any differently in the case a member never served.

If it is of any help, my NARSUM stated simply that while a bicuspid valve is a congenital condition I had no symptoms or any signs of regurgitation/stenosis/murmur prior to entering active duty. It also stated that I completed my initial military training without symptoms and without incident, it was not until a deployment to Iraq that I began showing symptoms that precipitated an investigation into my heart function. I think this chronological explanation of symptoms (and/or lack thereof) painted a very simple picture for the PEB to evaluate. Your case in similar insofar as you did not have any serious symptoms until well into your service. Try not to worry about the EPTS issue!

If you are found fit for duty and your condition becomes worse down the road (unable to perform PT, etc) it is possible that your command may try to administratively separate you, but keep in mind that this course of action is not correct nor is it legal (and if it does occur, it is most likely grounds for an appeal ex post facto). With your condition becoming worse, you should simply be processed through another MEB/PEB. Hopefully you never have to cross that bridge, but if you do come to it, the regulations and law are on your side.

Good luck with the rest of the process and be sure to keep us updated.

carr23,

Cardiac ratings - as stated earlier in this thread - are contingent on the results of stress tests, EKGs, echos, TEEs or any combination thereof. Once you have some baseline numbers, refer to VA code 7000 for valvular heart disease and check out the rating criteria. You will note that the METS rating (from a stress test) and the ejection fraction (from a nuclear stress test, echo, or TEE) are the important numbers for rating purposes.

Well the results of my IPEB came back in today..0%, existed prior to service, no severance pay. So much for accepted medical principles and published medical material eh?

Any suggestions?
 
Demand a Formal PEB. It is mainly in the nature of a legal argument regarding EPTS, however, it may be helpful to get a physician to say your condition worsened during service beyond what would be normally expected of someone with your condition.
 
Demand a Formal PEB. It is mainly in the nature of a legal argument regarding EPTS, however, it may be helpful to get a physician to say your condition worsened during service beyond what would be normally expected of someone with your condition.

Is there any advantage to me in trying to stretch this out until I hit 8 years of service (I have slightly less than 7 1/2 now)?
 
Yes, clearly. You will then be able to take advantage of the 8 year rule.
 
Yes, clearly. You will then be able to take advantage of the 8 year rule.

If I tell the formal PEB that is my intention, will they allow me to collect the severance now knowing that they will end up paying me eventually anyways? I have six months until my eight year mark. If I appeal the IPEB decision, it will be probably be 2 months until I make it to the formal board, and if I disagree with that decision it will probably be another 2-3 months to hear back from the SAFPC. If you add the 60-90 days that it takes to seperate once the final decision is made, that gets me to eight years.

I also feel like they kind of "bought the product" when they commissioned me in 2003 knowing I had his condition, and then allowed me to remain on active duty after I appealed to the SAFPC in 2004.

What do you think? Thanks
 
Not sure that they would catch that or that it would change the time processing of your case....but I would not tell them about your tactical decisions. Seems likely that you may be able to stretch this out by just demanding your formal hearing and appealing if you get a bad decision from the FPEB.

I am not sure that I understand your question about accepting severance now because "they will end up paying" you eventually. Either way, I think your course of action is to demand your formal hearing. I also suspect that you are forecasting a faster case processing than will likely happen.
 
Everybody on this board is great..thanks for the help with the questions.

I have one more though. Just to recap...my package went before the informal board and the recommendation was discharge without severance due to the fact that my valve disease was EPTS. I have 7 1/2 years of service so am short of the 8 year point so currently I can't use the "8 year rule".

I am going to the formal board in two weeks..if the outcome there is the same, I plan on appealing to the SAFPC and have heard that it can take 8-10 months to get an answer back..that puts me over the 8 year point easy. Here is my scenario...in June I hit eight years..if I don't hear back from the SAFPC but want to just get a job and get on with my life (or a really good opportunity presents itself), can I waive the SAFPC appeal, separate, and then request via the BCMR that my discharge be changed to discharge with severance because I had eight years of service? Should I hire an attorney if I want to go this route?

Thank you
 
Everybody on this board is great..thanks for the help with the questions.

I have one more though. Just to recap...my package went before the informal board and the recommendation was discharge without severance due to the fact that my valve disease was EPTS. I have 7 1/2 years of service so am short of the 8 year point so currently I can't use the "8 year rule".

I am going to the formal board in two weeks..if the outcome there is the same, I plan on appealing to the SAFPC and have heard that it can take 8-10 months to get an answer back..that puts me over the 8 year point easy. Here is my scenario...in June I hit eight years..if I don't hear back from the SAFPC but want to just get a job and get on with my life (or a really good opportunity presents itself), can I waive the SAFPC appeal, separate, and then request via the BCMR that my discharge be changed to discharge with severance because I had eight years of service? Should I hire an attorney if I want to go this route?

Thank you

Does anyone have any suggestions on my question above? Thanks again!
 
Everybody on this board is great..thanks for the help with the questions.

I have one more though. Just to recap...my package went before the informal board and the recommendation was discharge without severance due to the fact that my valve disease was EPTS. I have 7 1/2 years of service so am short of the 8 year point so currently I can't use the "8 year rule".

I am going to the formal board in two weeks..if the outcome there is the same, I plan on appealing to the SAFPC and have heard that it can take 8-10 months to get an answer back..that puts me over the 8 year point easy. Here is my scenario...in June I hit eight years..if I don't hear back from the SAFPC but want to just get a job and get on with my life (or a really good opportunity presents itself), can I waive the SAFPC appeal, separate, and then request via the BCMR that my discharge be changed to discharge with severance because I had eight years of service? Should I hire an attorney if I want to go this route?

Thank you

There is not much on this situation in the regulations. I would think that any "waiver" would have to be accepted and I am not sure that the SECAF would go for this (one of the purposes of the DES is to assess whether you would be available for later duty in a call up/total mobilization or for later reserve service). Except for the part about getting out early/when you want (at that point in the appeal process), I think your reasoning is sound. In fact, I might discuss bringing this topic up with your attorney at the FPEB. I can't promise this would be how they view it, but coincidentally, about 2 months ago, I overheard one of the AF PEB members looking at a packet with a similar set of facts and he essentially said that they would probably just reconsider the case based on the proximity to 8 years.

Not sure what point you are talking about retaining an attorney. If your rating under the VASRD is clear cut and there are no other issues than the EPTS, I would think you could go either way (with appointed counsel or a private attorney). At later points in the process, a civilian attorney may likely be a good idea. But, as always, it depends on the facts of your case (and much will depend on what your PEB decision states).

Good luck!
 
There is not much on this situation in the regulations. I would think that any "waiver" would have to be accepted and I am not sure that the SECAF would go for this (one of the purposes of the DES is to assess whether you would be available for later duty in a call up/total mobilization or for later reserve service). Except for the part about getting out early/when you want (at that point in the appeal process), I think your reasoning is sound. In fact, I might discuss bringing this topic up with your attorney at the FPEB. I can't promise this would be how they view it, but coincidentally, about 2 months ago, I overheard one of the AF PEB members looking at a packet with a similar set of facts and he essentially said that they would probably just reconsider the case based on the proximity to 8 years.

Not sure what point you are talking about retaining an attorney. If your rating under the VASRD is clear cut and there are no other issues than the EPTS, I would think you could go either way (with appointed counsel or a private attorney). At later points in the process, a civilian attorney may likely be a good idea. But, as always, it depends on the facts of your case (and much will depend on what your PEB decision states).

Good luck!

Hi Jason. Thanks for the response. What I meant about waiving the appeal, is that I was told by my disability attorney that I could appeal to the SAFPC, and then withdraw that appeal at any time (like if I got a really good job offer or got tired of waiting) and accept the findings of the formal PEB (which I assume will be a finding of unfit and discharge).

However since I will have over 8 years of service at that point, I would appeal to the BCMR as a civilian requesting severance pay due to the 8 year rule.


Thanks
 
Top