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From the 11/12/2021 release of VAERS data:

This is VAERS ID 1377491

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Case Details

VAERS ID: 1377491 (history)  
Form: Version 2.0  
Sex: Male  
Location: Foreign  
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-06-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: ?
Symptoms: Cardio-respiratory arrest, Cardiogenic shock
SMQs:, Torsade de pointes/QT prolongation (broad), Cardiac failure (narrow), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Respiratory failure (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-05-19
   Days after onset: 1
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:
Current Illness: Diabetes mellitus non-insulin-dependent (NIDDM)
Preexisting Conditions:
Diagnostic Lab Data:
CDC Split Type: ATPFIZER INC2021590479

Write-up: Cardio-respiratory arrest; Cardiogenic shock; This is a spontaneous report from a contactable physician. This is a report received from the Agency Regulatory Authority-WEB. Regulatory authority or other manufacturer number AT-BASGAGES-2021-28078. A 64-years-old male patient received the first dose of BNT162B2 (COMIRNATY), via an unspecified route of administration on 14May2021 (Batch/Lot Number: FA4598) as single dose for covid-19 immunisation. Medical history included ongoing diabetes mellitus non-insulin-dependent (NIDDM). The patient''s concomitant medications were not reported. On 18May2021 18:10 the patient experienced Cardio-respiratory arrest, hospitalization, life threatening. 18May2021 ~18:10 patient collapsed while gardening -$g Cardiopulmonary resuscitation ca.45 min, stabilization after lysis therapy (10,000 IU metalysis 18:35). 18:50 Return of Spontaneous Circulation (ROSC) -$g transfer. Treatment of side effect: noradrenaline 10mg/50ml to 1?g/kg/min 18May to 19May and levosimendan 12.5 mg for stabilization. Sevorane (MAC 0.8-1.0) and Ultiva 5mg/50ml for sedation. The pat died in cardiogenic shock at 06:05 on 19May2021. The patient''s outcome was: recovered/resolved for cardio-respiratory arrest, fatal for cardiogenic shock. An autopsy was ordered. No follow-up attempts possible. No further information expected.; Reported Cause(s) of Death: cardiogenic shock

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