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From the 10/8/2021 release of VAERS data:

This is VAERS ID 1666949

Case Details

VAERS ID: 1666949 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: New Jersey  
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-09-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Private       Purchased by: ?
Symptoms: Acute respiratory failure, Arrhythmia, Atrial fibrillation, Carbon dioxide increased, Death, Dyspnoea, Endotracheal intubation, Hypercapnia, Hypotension, Hypoxia, Intensive care, Malaise, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (narrow), Angioedema (broad), Asthma/bronchospasm (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Supraventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-02
   Days after onset: 74
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 12 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Please check with PCP
Current Illness: None
Preexisting Conditions: High blood pressure
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Within hours was short of breath climbing stairs he climbed daily and it never happened before. Doctor diagnosed that his heart was out of rhythm at next appointment. He was treated with a few different drugs but it couldn''t be controlled and he never felt well again. On 4/19/21 he was transported to Hospital by ambulance with AFib. The next morning he was found unresponsive and moved to ICU. His oxygen level was low and carbon dioxide level was high. For 2 weeks he suffered greatly. Doctors tried to balance his high heart rate with his low blood pressure. He was intubated twice. He died on May 2, 2021. His cause of death was acute respiratory failure with hypercapnia and hypoxemia. He had never had heart or lung problems before that.

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