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From the 11/19/2021 release of VAERS data:

This is VAERS ID 1755790

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Case Details

VAERS ID: 1755790 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-10-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Alanine aminotransferase, Brain natriuretic peptide, Cardiac failure congestive, Dyspnoea, Fibrin D dimer, Hepatic enzyme
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-28
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:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Test Name: ALT; Result Unstructured Data: elevated; Test Name: BNP; Result Unstructured Data: elevated; Test Name: D-Dimer; Result Unstructured Data: elevated; Test Name: Liver Enzymes; Result Unstructured Data: elevated
CDC Split Type: USMODERNATX, INC.MOD20213

Write-up: congestive heart failure; short of breath; This spontaneous case was reported by a consumer and describes the occurrence of CARDIAC FAILURE CONGESTIVE (congestive heart failure) and DYSPNOEA (short of breath) in a male patient of an unknown age who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. No Medical History information was reported. On an unknown date, the patient received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On an unknown date, the patient experienced CARDIAC FAILURE CONGESTIVE (congestive heart failure) (seriousness criteria death, hospitalization and medically significant) and DYSPNOEA (short of breath) (seriousness criteria death, hospitalization and medically significant). The patient died on 28-Aug-2021. The reported cause of death was Congestive heart failure and Short of breath. It is unknown if an autopsy was performed. DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On an unknown date, Alanine aminotransferase: elevated (High) elevated. On an unknown date, Brain natriuretic peptide: elevated (High) elevated. On an unknown date, Fibrin D dimer: elevated (High) elevated. On an unknown date, Hepatic enzyme: elevated (High) elevated. No concomitant medication details was provided. No treatment medication details was provided. Company comment: This case concerns a male patient of an unknown age with no previous relevant medical reported, who experienced the unexpected events of cardiac failure congestive and dyspnoea. The events occurred on an unknown number of days after the second dose of mRNA-1273 and had fatal outcome after on an unknown number of days with date 28-Aug-2021. No autopsy report was provided. The rechallenge was not applicable since the events happened after the second dose. The benefit-risk relationship of mRNA-1273 is not affected by this report. Further information was requested.; Sender''s Comments: This case concerns a male patient of an unknown age with no previous relevant medical reported, who experienced the unexpected events of cardiac failure congestive and dyspnoea. The events occurred on an unknown number of days after the second dose of mRNA-1273 and had fatal outcome after on an unknown number of days with date 28-Aug-2021. No autopsy report was provided. The rechallenge was not applicable since the events happened after the second dose. The benefit-risk relationship of mRNA-1273 is not affected by this report. Further information was requested.; Reported Cause(s) of Death: congestive heart failure; short of breath


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