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From the 11/26/2021 release of VAERS data:

This is VAERS ID 1431781

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Case Details

VAERS ID: 1431781 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Foreign  
Vaccinated:2021-04-27
Onset:2021-06-09
   Days after vaccination:43
Submitted: 0000-00-00
Entered: 2021-06-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Arrhythmia, Cardiac arrest, Myocarditis, Ventricular fibrillation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

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:
Current Illness: Hypothyreosis; Variant angina
Preexisting Conditions: Medical History/Concurrent Conditions: Gastritis
Allergies:
Diagnostic Lab Data:
CDC Split Type: DEPEI202100100794

Write-up: Myocarditis; Cardiac arrest; Cardiac arrhythmia; Ventricular fibrillation; This regulatory authority case was reported by a physician and describes the occurrence of MYOCARDITIS (Myocarditis), CARDIAC ARREST (Cardiac arrest), ARRHYTHMIA (Cardiac arrhythmia) and VENTRICULAR FIBRILLATION (Ventricular fibrillation) in a 65-year-old male patient who received mRNA-1273 (COVID 19 Vaccine Moderna) (batch no. 3002620) for COVID-19 vaccination and Prophylactic vaccination. The patient''s past medical history included Gastritis. Concurrent medical conditions included Hypothyreosis and Variant angina. On 27-Apr-2021, the patient received first dose of mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular) 1 dosage form. On 08-Jun-2021, received second dose of mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular) dosage was changed to 1 dosage form. On 09-Jun-2021, the patient experienced MYOCARDITIS (Myocarditis) (seriousness criteria death, hospitalization and medically significant), CARDIAC ARREST (Cardiac arrest) (seriousness criteria death, hospitalization and medically significant), ARRHYTHMIA (Cardiac arrhythmia) (seriousness criteria death, hospitalization and medically significant) and VENTRICULAR FIBRILLATION (Ventricular fibrillation) (seriousness criteria death, hospitalization and medically significant). The patient was hospitalized on 09-Jun-2021 due to ARRHYTHMIA, CARDIAC ARREST, MYOCARDITIS and VENTRICULAR FIBRILLATION. The reported cause of death was Heart arrest. It is unknown if an autopsy was performed. For mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular), the reporter did not provide any causality assessments. Concomitant medication were not provided. Treatment included cardiopulmonary resuscitation for the cardiac arrest. The action taken with mRNA 1273 with the events was considered as not applicable. This is a case of death in a 65-year-old male patient, that occurred 1 day after receiving the second dose of vaccine (Lot number 3002620). Based on the provided information, the patient had cardiac arrest and expired. A possible confounding factor is the patient''s medical history of variant angina. No further information is expected.; Sender''s Comments: This is a case of death in a 65-year-old male patient, that occurred 1 day after receiving the second dose of vaccine (Lot number 3002620). Based on the provided information, the patient had cardiac arrest and expired. A possible confounding factor is the patient''s medical history of variant angina. No further information is expected.; Reported Cause(s) of Death: Heart arrest


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