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From the 10/15/2021 release of VAERS data:

This is VAERS ID 1109864



Case Details

VAERS ID: 1109864 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Foreign  
Vaccinated:2021-02-04
Onset:2021-02-06
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EM0477 / 1 - / -

Administered by: Other       Purchased by: ?
Symptoms: Arrhythmia
SMQs:, Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: FUROSEMIDE; METOPROLOL; NEULEPTIL [PERICIAZINE]; PERINDOPRIL ERBUMINE; AMIODARON [AMIODARONE]; ACENOCOUMAROL; ROSUVASTATINE [ROSUVASTATIN]; GLUCIENT SR
Current Illness: Arrhythmia; Implantable cardioverter defibrillator insertion
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: NLPFIZER INC2021256558

Write-up: Arrhythmia; This is a spontaneous report from a contactable physician via the Agency (LRB), downloaded from the Agency Regulatory Agency-WEB (NL-LRB-00454760). A 70-year-old male patient received the first dose of BNT162B2 (COMIRNATY; Lot number EM0477) via an unspecified route of administration on 04Feb2021 at single dose for COVID-19 immunisation. Relevant medical history included ongoing implantable defibrillator insertion and ongoing arrhythmia. Concomitant medications included furosemide 40 mg, metoprolol 100 mg, periciazine (NEULEPTIL) 5 mg, perindopril erbumine 2 mg, amiodarone (AMIODARON) 200 mg, acenocoumarol 1 mg, rosuvastatin [ROSUVASTATINE] 10 mg and metformin hydrochloride (GLUCIENT SR) 500 mg. On 06Feb2021, the patient experienced arrhythmia for which he was hospitalized on the same day. The reporter specified that the patient had previous hospitalization''s due to this arrhythmia. After a hospitalization of 2 weeks, the patient deceased on an unspecified date in 2021. It was not reported if an autopsy was performed. No follow-up attempts are possible. No further information is expected.; Reported Cause(s) of Death: Based on his known heart rhythm problem


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