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From the 9/17/2021 release of VAERS data:

This is VAERS ID 1498080



Case Details

VAERS ID: 1498080 (history)  
Form: Version 2.0  
Age: 15.0  
Sex: Male  
Location: New York  
Vaccinated:2021-07-18
Onset:2021-07-22
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-07-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0196 / 1 LA / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0198 / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Resuscitation, Syncope, Ventricular tachycardia
SMQs:, Torsade de pointes/QT prolongation (narrow), Arrhythmia related investigations, signs and symptoms (broad), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-07-22
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Lopressor 25mg BID
Current Illness: Diagnosed May 2021 hypertrophic cardiomyopathy
Preexisting Conditions: Diagnosed May 2021 hypertrophic cardiomyopathy
Allergies: unknown
Diagnostic Lab Data: none at this time
CDC Split Type:

Write-up: 7/22/2021 Child collapsed on soccer field while playing soccer at a local camp. CPR was initiated immediately. EMS arrived and found patient in vtac. Shock x 5. ACLS, intubation attempted. Transported to Medical Center. Patient had covid in April 2021. Dx in May 2021 hypertrophic cardiomyopathy. Started on lopressor 25mg BID. Patient had reported to parents that he had not recently taken his medications. Patient had his second covid vaccine on Sunday 7/18/2021.


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