BMP10 for assessing right heart function in patients with heart valve diseases

Abstract

The present invention concerns the field of diagnostics. In particular. It relates to a method for assessing a heart valve disease or disorder comprising the steps of a) determining the amount of a BMPlO-type peptide in a sample of said subject, and b) comparing the amount determined in step a) to a reference, whereby the heart valve disease or disorder is assessed. Further, the invention concerns computer-implemented methods of the aforementioned methods as well as devices and kits for carrying out said methods. Yet, the present invention contemplates the general use of a BMPlO-type peptide in a sample of a subject or a detection agent for a BMPlO-type peptide to be applied in said sample for assessing a heart valve disease or disorder.

Description

[0001] Roche Diagnostics GmbH RD17334PC AD / JK Roche Diagnostics International AG

[0002] BMP10 for assessing right heart function in patients with heart valve diseases

[0003] The present invention concerns the field of diagnostics. In particular. It relates to a method for assessing a heart valve disease or disorder comprising the steps of a) determining the amount of a BMP10-type peptide in a sample of said subject, and b) comparing the amount determined in step a) to a reference, in order to assess the heart valve disease or disorder. Further, the invention concerns computer-implemented methods of the aforementioned methods as well as devices and kits for carrying out said methods. Yet, the present invention contemplates the general use of a BMPlO-type peptide in a sample of a subject or a detection agent for a BMP10-type peptide to be applied in said sample for assessing a heart valve disease or disorder.

[0004] In patients with heart failure, assessing the presence of symptoms and signs of right heart failure (RHF) is crucial for decision making and risk stratification (Dietz 2020 J Am Coll Cardiol HF;8:627-36). RHF is clinically diagnosed by functional loss based on reduced exercise capacity and / or signs of right-sided decompensation (Gorter 2018 Eur J Heart Fail;20, 16-37). Similar to left heart failure, RHF is a progressive condition that can be divided into stages. RHF and tricuspid regurgitation (TR) are prevalent conditions that significantly impact quality of life and are strongly associated with increased risks of heart failure hospitalization and mortality (Heitzinger 2023 Eur J Heart Fail;25:857-867). TR and RHF can result from various causes, including left ventricular (LV) failure, regardless of LV ejection fraction (LVEF), left-sided valvular heart disease (VHD), primary right ventricular dysfunction (RVD), pulmonary arterial hypertension, and lung disorders. Additionally, permanent atrial fibrillation (AF) and atrial disorders can lead to secondary TR due to right atrial remodeling and tricuspid annulus dilatation. Furthermore, right-heart sided leads from pacemakers, implantable cardiac defibrillators (ICD), or cardiac resynchronization therapy (CRT) can contribute to secondary TR and RHF. Although rare in adults, primary TR can also cause RHF.

[0005] Patients with severe tricuspid regurgitation (TR) are often diagnosed at a late stage, when tissue changes and symptoms of right heart failure (RHF) are advanced and treatment options for intervention are limited (Adamo 2024 Eur J Heart Fail;26, 18-33). In such cases, surgical treatment for isolated TR carries a high intraoperative risk, and medical therapies tend to beineffective. While catheter-based interventions are emerging as potential treatment alternatives for these patients, it remains unclear how to identify those who would benefit most from these procedures with predicted outcome. As a result, determining the optimal management of RHF and TR, as well as the ideal timing for interventions, represents an important unmet medical need.

[0006] Right ventricular (RV) function is one of the main determinants of postoperative outcomes in patients with secondary tricuspid regurgitation (TR). Nevertheless, there are currently no specific recommendations for RV functional parameters values that can predict the outcome of isolated tricuspid valve interventions. Additionally, characterizing these parameters using 2D echocardiography is challenging due to the complex geometry of the right ventricle and the interplay between RV myocardial performance and loading conditions. Furthermore, the RV is better able to tolerate volume overload than pressure overload, and RV remodeling may occur before RV dysfunction becomes evident, often only at the later stages of TR (Dietz 2020 J Am Coll Cardiol HF;8:627-36). In most of the clinical trials and commonly in clinical routine, the RV assessment is conducted using TAPSE (tricuspid annular plane systolic excursion), an echocardiographic parameter evaluating RV longitudinal function and that does not reflect right ventricular function after cardiac surgery (Cersosimo 2024 J Cardiovasc Med;25:95-103). Although RV dysfunction based on TAPSE is associated with poor outcomes in patients with significant secondary TR, it doesn’t make the RV function assessment, nor outcome prediction, accurate enough.

[0007] Pulmonary hypertension (PH) is a severe and complex disease characterized by abnormally high pressure in the pulmonary arteries that eventually leads to right ventricular dysfunction and right heart failure (Humbert 2022, Eur Heart J. 43:3618-3731). In turn, PH is found as a common and severe complication of heart failure (HF). In PH, both elevation of left atrial filling pressure (post-capillary component) and an increase in pulmonary vascular resistance (precapillary component) contribute to the elevation of the mean pulmonary arterial pressure (mPAP). Accordingly, pulmonary hypertension is typically associated with improper circulation and hemodynamics resulting in congestion causing an increase of pressure in the vascular system.

[0008] The surgical outcomes for patients with isolated TR continue to be among the poorest across all types of valve surgery (Muntane-Carol 2021, Circ Cardiovasc Interv;14:e009685). The presence of right heart failure (RHF) and pulmonary hypertension (PH) have been recognized as two key factors that contribute to worse outcomes in both the natural progression of TR and after surgery. These factors, which likely indicate a more advanced stage of the disease, may lead to a higher incidence of periprocedural complications, including an increased risk of further RV dysfunction and death. Transcatheter tricuspid valve intervention (TTVI) has also beenlinked to worse outcomes in patients with RV dysfunction and PH, raising potential concerns about the futility of treatment in these cases. In addition, literature indicates that patients should undergo tricuspid valve repair or replacement before developing precapillary PH and experiencing an increase in pulmonary vascular resistance, as this may offer a potential survival benefit (Vijayaraghavan 2021, CJC Open; volume 3). Together, these results highlight the importance of invasive hemodynamic data for effective risk stratification in patients undergoing tricuspid valve surgery.

[0009] A blood-based biomarkers able to determine the pre-capillary component of PH, and thus to monitor the progressive increase in pulmonary vascular resistance through longitudinal measurements, would offer the possibility of avoiding serial invasive right heart catheterizations for pulmonary hemodynamics monitoring. Moreover, blood-based biomarkers might help to assess the progression of tissue changes and right ventricular (RV) function and thus, to better stratify patients into right heart failure stages and in the context of tricuspid regurgitation (TR), they may help in selecting those patients without severe right RV dysfunction, and without severe increase of pulmonary vascular resistance, and who are asymptomatic despite significant TR. Treating these patients earlier may prevent further damage of the RV and improve survival.

[0010] Based on the functional loss, it has been observed that the regurgitation leads to tissue adaptation (e.g. fibrosis) and thus different expressions and release of biomarkers into the circulation, where reversible patho-anatomical tissue changes in the right ventricle will slide into irreversible damage (Carrascal 2023 Rev Esp Cardiol (Engl Ed); 76:453-459), where tissue- and disease-specific biomarkers were lacking so far.

[0011] Bone morphogenetic protein 10 (BMP 10), a member of the transforming growth factor β (TGF-β) superfamily, has been recently found as a cardiac-specific biomarker predominantly expressed in the right atrium (Mikryukov 2021, Cell Stem Cell. 28(1):96-111.e7; Reyat 2020, JCI Insight 5(16)). BMP10 was shown to be associated with ischemic stroke and major adverse cardiovascular events in patients with atrial fibrillation (AF) (Hijazi 2023, Eur Heart J 44(3):208-18; Hennings 2023, J Am Heart Assoc. 12(6):e028255). Ligands of this family bind various TGF-beta receptors leading to recruitment and activation of certain transcription factors that regulate gene expression. BMP 10 binds to the activin receptor-like kinase 1 (ALK1) and has been shown to be a functional activator of this kinase in endothelial cells (David 2007, Blood, 109(5): 1953-61). BMP10 plays a central role in cardiac embryogenesis, vascular smooth muscle cell (VSMC) contractility and maintenance, as well as playing a cardio-protective and anti-fibrotic function after cardiac injury (Wang 2021, Circulation, 143(14): 1394-410; Qu 2019, J Biol Chem. 294(52): 19877-88; Sun 2014, Cell Biochem, 115(11): 1868-76).There is a need to identify and evaluate biomarkers as predictors of short and longer-term clinical outcome and for helping in the assessment of right heart function such as the assessment of heart valve diseases or disorders such as TR, right ventricular function and in the risk stratification of associated diseases such as right heart failure in order to improve therapies.

[0012] Thus, the technical problem underlying the present invention may be seen as the provision of means and methods complying the aforementioned needs. The technical problem is solved by the embodiments characterized in the claims and herein below.

[0013] The present invention relates to a method for assessing a heart valve disease or disorder comprising the steps of:

[0014] a) determining the amount of a BMP10-type peptide in a sample of said subject; and

[0015] b) comparing the amount determined in step a) to a reference, whereby the heart valve disease or disorder is assessed.

[0016] Preferably, the method comprises step c) assessing the heart valve disease or disorder based on the comparison made in step b)

[0017] As used in the following, the terms “have”, “comprise” or “include” are meant to have a nonlimiting meaning or a limiting meaning. Thus, having a limiting meaning these terms may refer to a situation in which, besides the feature introduced by these terms, no other features are present in an embodiment described, i.e. the terms have a limiting meaning in the sense of “consisting of’ or “essentially consisting of’. Having a non-limiting meaning, the terms refer to a situation where besides the feature introduced by these terms, one or more other features are present in an embodiment described.

[0018] Further, as used in the following, the terms “preferably”, “more preferably”, “most prefer-ably”, "particularly", "more particularly", “typically”, and “more typically” are used in conjunction with features in order to indicate that these features are preferred features, i.e. the terms shall indicate that the recited features are pivotally envisaged in accordance with the invention but alternative features may yet also be envisaged.

[0019] Further, it will be understood that the term “at least one” as used herein means that one or more of the items referred to following the term may be used in accordance with the invention. For example, if the term indicates that at least one item shall be used this may be understood as one item or more than one item, i.e. two, three, four, five or any other number. Depending on theitem the term refers to the skilled person understands as to what upper limit the term may refer, if any.

[0020] The method as referred to in accordance with the present invention includes a method which essentially consists of the aforementioned steps or a method which includes further steps. Moreover, the method of the present invention, preferably, is an ex vivo method, i.e. not practiced on the human or animal body, and, more preferably, an in vitro method. Moreover, it may comprise steps in addition to those explicitly mentioned above. For ex-ample, further steps may relate to the determination of further markers and / or to sample pre-treatments or evaluation of the results obtained by the method. The method may be carried out manually or assisted by automation. Preferably, step (a) and / or (b) may in total or in part be assisted by automation, e.g., by a suitable robotic and sensory equipment for the determination in step (a) or a computer-implemented calculation in step (b). Preferably, the in the method of the present invention, step b) of said method is computer-implemented.

[0021] The term “assessing” as used herein refers to evaluating the heart valve disease or disorder and / or any associated diseases or disorders that are, preferably, causing the heart valve disease or disorder or that are, preferably, caused by the heart valve disease or disorder. Assessing in accordance with the present invention includes diagnosing, staging, monitoring, and / or predicting the heart valve diseases or disorder. Diagnosing as used herein means determining the presence (rule-in diagnosis) or absence (rule-out diagnosis) of a disease or disorder. Staging as used herein refers to allocating a stage or degree to a patient suffering from a disease or disorder, e.g. a disease or disorder may be at a mild stage or may be developed to a moderate or advance stage, typically, associated with more severe symptoms and comorbidities. Monitoring as used herein refers to diagnosing the presence or absence of a disease or disorder at least two and, preferably, a plurality of time points over a time window or to staging the disease or disorder at least two and, preferably, a plurality of time points over a time window. Predicting as used in accordance with the present invention relates to determining the likelihood based on which a subject will develop a certain disease or disorder or a certain endpoint associated with a disease or disorder over a predefined time window (i.e. predictive window). Predicting also encompasses determining the likelihood of postoperative outcomes as endpoints. As will be understood by those skilled in the art, the assessment of the present invention is usually not intended to be correct for 100% of the subjects to be tested. However, the term requires that a correct assessment (such as the diagnosis, differentiation, prediction, identification or assessment of a therapy as referred to herein) can be made for a relevant portion of subjects within a given cohort and, preferably, for a statistically significant portion of subjects within a given cohort. Whether a portion is statistically significant can be determined without further ado by the person skilled in the art using various well known statistic evaluation tools, e.g., determination of confidence intervals, p-value determination, Student's t-test, Mann-Whitney test etc. Details are found in Dowdy and Wearden, Statistics for Research, John Wiley & Sons, New York 1983. Preferred confidence intervals are at least 90%, at least 95%, at least 97%, at least 98%, or at least 99%. The p-values are, preferably, 0.4, 0.1, 0.05, 0.01, 0.005, or 0.0001.

[0022] In a preferred embodiment of the method of the present invention, said assessing comprises staging of TR. Preferably, assessing is used to allocate the investigated subject to one of the following stages of TR as determined by echocardiography and, preferably, 2D echocardiography: no TR, minimal TR, mild TR, moderate TR or severe TR. Thus, the present invention in a preferred embodiment concerns a method for staging of TR, the method comprising the steps of:

[0023] a) determining the amount of a BMP10-type peptide in a sample of said subject; and b) comparing the amount determined in step a) to a reference, and

[0024] c) staging TR in said subject based on the comparison made in step b).

[0025] In a preferred embodiment of the method of the present invention, said assessing comprises providing a recommendation for heart valve disease or disorder therapy, preferably, tricuspid valve repair or replacement. It will be understood that the recommendation for heart valve disease or disorder is typically given if the subject will benefit from the therapy, i.e. if the therapy is likely to be successful (rule-in recommendation). However, a recommendation may also be a suggestion to avoid the heart valve disease or disorder therapy (rule-out recommendation), e.g., in cases where a subject will not benefit from the therapy or be at risk of developing side effects. Thus, the present invention in a preferred embodiment concerns a method for providing a recommendation for heart valve disease or disorder therapy, preferably, tricuspid valve repair or replacement, the method comprising the steps of:

[0026] a) determining the amount of a BMP10-type peptide in a sample of said subject; and b) comparing the amount determined in step a) to a reference, and

[0027] c) providing a recommendation for heart valve disease or disorder therapy, preferably, tricuspid valve repair or replacement in said subject based on the comparison made in step b).

[0028] In yet a preferred embodiment of the method of the present invention, said assessing comprises predicting or monitoring the outcome of a therapy of a heart valve disease or disorder, preferably, tricuspid repair or replacement. Predicting and / or monitoring of the development of a heart valve disease or disorder may, particularly, be relevant in cases where a subject is at risk of worsening. This is, preferably, the case if the heart valve disease or disorder is associated with right heart failure and / or pulmonary hypertension and / or have been treated by transcatheter tricuspid intervention (TTVI). Thus, the present invention in a preferred embodiment concernsa method for predicting or monitoring the outcome of a heart valve disease or disorder therapy, preferably, tricuspid repair or replacement, the method comprising the steps of:

[0029] a) determining the amount of a BMP10-type peptide in a sample of said subject; and b) comparing the amount determined in step a) to a reference, and

[0030] c) predicting or monitoring the outcome of a heart valve disease or disorder therapy, preferably, tricuspid repair or replacement in said subject based on the comparison made in step b).

[0031] In a further preferred embodiment of the method of the present invention, said assessing the heart valve disease or disorder further comprises assessing right heart failure, right atrial dilation, right ventricular dysfunction, and / or pulmonary hypertension. Stratifying right heart dysfunctions and, preferably, right heart failure, right atrial dilation, right ventricular dysfunction, and / or pulmonary hypertension in the context of heart valve diseases or disorders such as TR may, preferably, help in identifying subjects with or without severe right heart dysfunction, with or without severe pulmonary hypertension, and asymptomatic subjects despite significant heart valve diseases or disorders. Treating such subjects by suitable therapies at an early stage shall prevent further damage of the right heart and improve survival. Thus, the present invention in a preferred embodiment concerns a method for assessing right heart failure, right atrial dilation, right ventricular dysfunction, and / or pulmonary hypertension in a subject suffering from or suspected to suffer from a heart valve disease or disorder, the method comprising the steps of:

[0032] a) determining the amount of a BMP10-type peptide in a sample of said subject; and b) comparing the amount determined in step a) to a reference, and

[0033] c) assessing right heart failure, right atrial dilation, right ventricular dysfunction, and / or pulmonary hypertension in said subject based on the comparison made in step b).

[0034] The term “heart valve disease or disorder” as used herein refers to any disease or disorder affecting the physiological function of a heart valve. Heart valve diseases or disorders are also sometimes referred to as valvular heart diseases. The heart has two atrioventricular valves separating the upper atria from the lower ventricles. The mitral valve in the left heart, i.e. separating the left ventricle from the left atrium, and the tricuspid valve in the right heart, i.e. separating the right ventricle from the right atrium. There are two semilunar valves which are at the entrance of the arteries leaving the heart. These are the aortic valve at the aorta and the pulmonary valve at the pulmonary artery. Preferably, the heart valve disease or disorder in accordance with the invention affects an atrioventricular valve and, more preferably, the tricuspid valve. Preferably, said heart valve disease or disorder is tricuspid regurgitation (TR).

[0035] The “subject” as referred to herein is, preferably, a mammal. Mammals include, but are not limited to, domesticated animals (e.g., cows, sheep, cats, dogs, and horses), primates (e.g.,humans and non-human primates such as monkeys), rabbits, and rodents (e.g., mice and rats). Preferably, the subject is a human subject. Preferably, the subject to be tested is of any age. Moreover, it is envisaged that the subject to be tested, preferably, does not exhibit right ventricular dysfunction and / or an increase of pulmonary vascular resistance and / or is asymptomatic despite significant TR. Preferably, said right ventricular dysfunction and / or pulmonary vascular resistance is of any degree between mild, moderate and severe. More preferably, said right ventricular dysfunction and / or pulmonary vascular resistance is severe right ventricular dysfunction and / or pulmonary vascular resistance.

[0036] The term “Bone Morphogenic Protein 10-type peptide” or “BMPlO-type peptide” as used herein refers to peptides being or being derived from the Bone Morphogenetic Protein 10 (BMP10). BMP10 belongs to the TGF-P superfamily of proteins and is required, e.g., for maintaining the proliferative activity of embryonic cardiomyocytes by preventing premature activation of the negative cell cycle regulator CDKN1C / p57KIP and maintaining the required expression levels of cardiogenic factors such as MEF2C and NKX2-5. BMP 10 also inhibits endothelial cell migration and growth. Several orthologues of BMP 10 have been reported in various animal species. Preferably, BMP 10 as referred to herein is human BMP 10 having an amino acid sequence as deposited under UniProt accession number 095393. It will be understood that the term also relates to variants of said proteins. It is to be understood that a variant as referred to in accordance with the present invention shall have an amino acid sequence which differs by at least one amino acid substitution, deletion and / or addition wherein their amino acid sequence of the variant is still, preferably, at least 50%, 60%, 70%, 80%, 85%, 90%, 92%, 95%, 97%, 98%, or 99% identical with the specific amino sequence of the human BMP 10 protein, preferably, over its entire length. Such variants shall have at least the same essential biological and immunological properties as human BMP10, preferably, those detectable by the specific assays referred to in this specification.

[0037] As a secreted protein, a BMP 10 protein referred to in accordance with the present invention is, typically, generated in a cell in an unprocessed prepro-form. During secretion, the said preproBMP10 is processed. Typically, preproBMP10 (UniProt accession number O95393-1) comprises a short signal peptide consisting of amino acids 1 to 21 which is enzymatically cleaved off to release proBMPlO. Accordingly, human proBMPIO comprises amino acids 22 to 424 of human preproBMPIO. Human proBMPIO is further cleaved into an N-terminal prosegment of BMP10 (NT-proBMP10) and non-glycosylated, mature BMP10, which is the biologically active form. NT-proBMP10 comprises amino acids 22 to 316 of the polypeptide. Since proBMP10 is cleaved into BMP10 and NT-proBMP10 in equimolar proportions, the amount of BMP 10 reflects the amount of the N-terminal prosegment and vice versa. Thus, the amount of a BMP 10 peptide can be determined by determining the amount of the N-terminal prosegment and vice versa.BMPlO-type peptides are well known in the art. Preferred BMP10-types peptide are, e.g., disclosed in Susan-Resiga et al. (Susan-Resiga et al., J Biol Chem. 2011 Jul 1; 286 (26):22785-94 or US2012 / 0213782). Preferably, a BMP10-type peptide according to the present inventionis selected from the group consisting of: mature BMP10, NT-proBMP10, proBMP10, andpreproBMP10. More preferably, a BMPlO-type peptide according to the present invention is selected from the group consisting of: NT-proBMPIO, proBMPIO, and preproBMPlO. Even more preferably, the BMPlO-type peptide is proBMPIO and / or NT-proBMPIO. Most preferably, the BMPlO-type peptide is NT-proBMPIO.

[0038] The BMPlO-type peptide according to the present invention may be part of a homo- or heterodimeric complex. In a heterodimeric complex, the BMPlO-type peptide may occur together with other BMPs and, preferably, together with BMP9.

[0039] In accordance with the present invention, the amount of BMPlO-type peptide shall be determined. The determination is, preferably, carried out with at least one detection agent for a BMP10-type peptide. Such a detection agent, typically, binds specifically to the BMP 10 peptide which shall be determined. Specific binding means that the detection agent shall bind the BMPlO-type peptide but not to other proteins or peptides comprised in a sample as referred to herein. Typically, a detection agent that specifically binds to a BMPlO-type peptide according to the invention, thus, binds to an amino acid sequence or three dimensional structure in the BMPlO-type peptide present under physiological conditions that is essentially unique for the BMPlO-type peptide to be detected. It will be understood that dependent on the sample, a potential sample pre-treatment and / or the nature of the detection agent, all BMPlO-type peptides can be determined that comprise the NT-proBMPIO amino acid sequence, such as proBMPIO, preproBMPlO and NT-proBMP10. Thus, when determining the amount of a BMPlO-type peptide according to the present invention the combined amounts (i.e. the sum of the amounts) of peptides is determined which have an amino acid sequence comprising NT-proBMPlO amino acid sequence, in particular, the combined amounts of proBMPIO, preproBMPlO and NT -proBMPIO. Since prepro-BMP10 is, in principle, not present in many samples, the term “BMPlO-type peptide” may also mean that the sum of NT-proBMPIO and proBMPIO is determined. Thus, the amount of NT-proBMPIO and / or BMP10 is determined.

[0040] The term “amount” as used herein refers to absolute as well as relative amounts of the BMPlO-type peptide. Thus, the BMPlO-type peptide shall be quantitatively determined. However, the term also encompasses the determination of the amount relative to a reference value, such as a reference volume, such as the sample volume or a predefined volume, an amount of a predetermined peptide or protein used as reference value, the total amount of peptide and proteins, the total sample mass, the amount of cells, and the like.The term “reference” as used herein refers to a parameter or value and, preferably, to a reference amount that allows for assessing a heart valve disease or disorder as specified elsewhere herein. Thus, based on the said reference for the BMPlO-type peptide and the determined amount for the BMPlO-type peptide in the sample of the subject, the said subject shall be allocated into an assessment group as referred to herein, elsewhere.

[0041] Preferably, said reference may be an amount for the BMP 10-type peptide derived from a subj ect or group of subjects known to exhibit the heart valve disease or disorder. More preferably, an amount for the BMP10-type peptide determined in the sample of the subject being essentially identical or increased compared to the reference is indicative for a subject suffering from the heart valve disease or disorder or suffering from a more advanced stage of the heart valve disease or disorder, whereas an amount for the BMPlO-type peptide determined in the sample of the subject being decreased compared to the reference is indicative for a subject which is not suffering from the heart valve disease or disorder or suffering from a less advanced stage of the heart valve disease or disorder.

[0042] Also preferably, said reference may be an amount for the BMP10-type peptide derived from a subject or group of subjects known not to exhibit the heart valve disease or disorder. More preferably, an amount for the BMP10-type peptide determined in the sample of the subject being essentially identical or decreased compared to the reference is indicative for a subject which is not suffering from the heart valve disease or disorder, whereas an amount for the BMP10-type peptide determined in the sample of the subject being increased compared to the reference is indicative for a subject at risk or suffering from the heart valve disease or disorder.

[0043] It will be understood that references for disease and disorders mentioned herein other than heart valve disease or disorders can be preferably derived and used in an analogous manner as described for references for heart valve disease or disorders before.

[0044] Thus, preferably, said reference may be an amount for the BMP10-type peptide derived from a subject or group of subjects known to exhibit the right heart failure, right atrial dilation, right ventricular dysfunction, and / or pulmonary hypertension and, preferably, having the heart valve disease or disorder. More preferably, an amount for the BMP10-type peptide determined in the sample of the subject being essentially identical or increased compared to the reference is indicative for a subject suffering from the right heart failure, right atrial dilation, right ventricular dysfunction, and / or pulmonary hypertension, whereas an amount for the BMPlO-type peptide determined in the sample of the subject being decreased compared to the reference is indicative for a subject which is not suffering from right heart failure, right atrial dilation, right ventricular dysfunction, and / or pulmonary hypertension.Also preferably, said reference may be an amount for the BMP10-type peptide derived from a subject or group of subjects known not to exhibit the right heart failure, right atrial dilation, right ventricular dysfunction, and / or pulmonary hypertension and, preferably, not having the heart valve disease or disorder. More preferably, an amount for the BMP10-type peptide determined in the sample of the subject being essentially identical or decreased compared to the reference is indicative for a subject which is not suffering from right heart failure, right atrial dilation, right ventricular dysfunction, and / or pulmonary hypertension, whereas an amount for the BMP10-type peptide determined in the sample of the subject being increased compared to the reference is indicative for a subject at risk or suffering right heart failure, right atrial dilation, right ventricular dysfunction, and / or pulmonary hypertension.

[0045] The term “sample” refers to a sample of a body fluid, to a sample of cells, tissue or an organ. Samples of body fluids can be obtained by well-known techniques and include, preferably, samples of blood, plasma, serum, urine, lymphatic fluid, interstitial fluids or derivatives thereof. Tissue or organ samples may be obtained from any tissue or organ by, e.g., biopsy. Cell-, tissue-or organ samples may be obtained from those cells, tissues or organs, which express or produce the biomarker. The sample may be frozen, fresh, fixed, e.g., formalin fixed, centrifuged, and / or embedded, e.g. paraffin embedded, etc. The sample can, of course, be subjected to a variety of well-known post-collection preparative and storage techniques. Such techniques may include nucleic acid and / or protein extraction, fixation, storage, freezing, ultrafiltration, concentration, evaporation, centrifugation, etc. and are, typically, carried out prior to assessing the amount of biomarkers in the sample. Preferably, the sample is a blood, more preferably, whole blood serum or plasma sample. Serum is the liquid fraction of whole blood that is obtained after the blood is allowed to clot. For obtaining the serum, the clot is removed by centrifugation and the supernatant is collected. Plasma is the acellular fluid portion of blood. For obtaining a plasma sample, whole blood is collected in anticoagulant-treated tubes, e.g., citrate-treated or EDTA-treated tubes. Cells are removed from the sample by centrifugation and the supernatant is obtained, i.e. the plasma sample.

[0046] In a preferred embodiment of the method of the present invention, the method is further comprising determining the amount of at least one further biomarkers selected from the group consisting of: a natriuretic peptide, preferably, N-terminal propeptide of B-type natriuretic peptide (NT -proBNP), myosin-binding protein C cardiac-type (MyBPC3), fibroblast growth factor 23 (FGF23), endothelial cell specific molecule 1 (ESM1), insulin like growth factor binding protein 7 (IGFBP7), growth differentiation factor 15 (GDF15), interleukin 6 (IL-6), angiopoietin 2 (ANG2), C-terminal fragment of type VI (a3) collagen (PRO-C6), and N-terminal type III collagen propeptide (PRO-C3).These biomarkers are also suitable for assessing conditions associated with a heart valve disease or disorder referred to herein, such as right heart failure, right atrial dilation, right ventricular dysfunction, and / or pulmonary hypertension. Moreover, the said biomarkers are also known as biomarkers for vascular remodeling, and vascular injury and inflammation. Therefore, the said biomarkers when determined in accordance with the method of the present invention may strengthen the assessment provided by determining a BMP10-type peptide as described above.

[0047] The term “natriuretic peptide” comprises atrial natriuretic peptide (ANP)-type and brain natriuretic peptide (BNP)-type peptides. Thus, natriuretic peptides according to the present invention comprise ANP-type and BNP -type peptides and variants thereof (see, e.g., Bonow RO. et al., Circulation 1996;93: 1946-1950). ANP-type peptides comprise pre-proANP, proANP, NT-proANP, and ANP. BNP -type peptides comprise pre-proBNP, proBNP, NT-proBNP, and BNP. The pre-pro peptide (134 amino acids in the case of pre-proBNP) comprises a short signal peptide, which is enzymatically cleaved off to release the pro peptide (108 amino acids in the case of proBNP). The pro peptide is further cleaved into an N-terminal pro peptide (NT -pro peptide, 76 amino acids in case of NT-proBNP) and the active hormone (32 amino acids in the case of BNP, 28 amino acids in the case of ANP). Preferred natriuretic peptides according to the present invention are NT-proANP, ANP, NT-proBNP, BNP. ANP and BNP are the active hormones and have a shorter half-life than their respective inactive counterparts, NT-proANP and NT-proBNP. BNP is metabolized in the blood, whereas NT-proBNP circulates in the blood as an intact molecule and as such is eliminated via the kidney. The most preferred natriuretic peptides according to the present invention are NT-proBNP and BNP, in particular NT-proBNP. As briefly discussed above, the human NT-proBNP as referred to in accordance with the present invention is a polypeptide comprising, preferably, 76 amino acids in length corresponding to the N-terminal portion of the human NT-proBNP molecule. The structure of the human BNP and NT-proBNP has been described already in detail in the prior art, e.g., WO 02 / 089657, WO 02 / 083913, and Bonow RO. Et al., New Insights into the cardiac natriuretic peptides. Circulation 1996;93: 1946-1950. Preferably, human NT-proBNP as used herein is human NT-proBNP as disclosed in EP 0648228 Bl.

[0048] The term “MyBPC3” as used herein refers to the myosin-binding protein C, cardiac-type encoded in humans by the MYBPC3 gene. It is crucial for sarcomere organization and maintenance of normal cardia function. In humans, two isoforms have been reported. Moreover, several orthologues have been reported in various animal species. The MyBPC3 protein referred to in accordance with the present invention is preferably human MyBPC3 having an amino acid sequence as deposited under UniProt accession number Q14896. It will be understood that the term MyBPC3 also relates to variants of said proteins. Such variants have at least the same essential biological and immunological proper-ties if they are detectable by the same specific assays referred to in this specification. Moreover, it is to be understood that avariant as referred to in accordance with the pre-sent invention shall have an amino acid sequence which differs due to at least one amino acid substitution, deletion and / or addition wherein the amino acid sequence of the variant is still, preferably at least 50%, 60%, 70%, 80%, 85%, 90%, 92%, 95%, 97%, 98%, or 99% identical with the specific amino sequence of the MyBPC3 protein, preferably over the entire length of the said MyBPC3 proteins, respectively.

[0049] The term “FGF23” as used herein refers to the fibroblast growth factor 23 encoded in humans by the FGF23 gene. It is essential in the regulation of phosphate homeostasis in plasma and vitamin D metabolism and decreases reabsorption of phosphate in the kidney. Several orthologues have been reported in various animal species. The FGF23 protein referred to in accordance with the present invention is preferably human FGF23 having an amino acid sequence as deposited under UniProt accession number Q9GZV9. It will be understood that the term FGF23 also relates to variants of said proteins. Such variants have at least the same essential biological and immunological properties if they are detectable by the same specific assays referred to in this specification. Moreover, it is to be understood that a variant as referred to in accordance with the present invention shall have an amino acid sequence which differs due to at least one amino acid substitution, deletion and / or addition wherein the amino acid sequence of the variant is still, preferably at least 50%, 60%, 70%, 80%, 85%, 90%, 92%, 95%, 97%, 98%, or 99% identical with the specific amino sequence of the FGF23 protein, preferably over the entire length of the said FGF23 proteins, respectively.

[0050] The term “ESM1” as used herein refers to the endothelial cell-specific molecule 1 encoded in humans by the ESM1 gene. It is mainly expressed in the endothelial cells in human lung and kidney tissue and may play a role in endothelium-dependent pathological disorders. Several orthologues have been reported in various animal species. The ESM1 protein referred to in accordance with the present invention is preferably human ESM1 having an amino acid sequence as deposited under UniProt accession number Q9NQ30. It will be understood that the term ESM1 also relates to variants of said proteins. Such variants have at least the same essential biological and immunological properties if they are detectable by the same specific assays referred to in this specification. Moreover, it is to be under-stood that a variant as referred to in accordance with the present invention shall have an amino acid sequence which differs due to at least one amino acid substitution, deletion and / or addition wherein the amino acid sequence of the variant is still, preferably at least 50%, 60%, 70%, 80%, 85%, 90%, 92%, 95%, 97%, 98%, or 99% identical with the specific amino sequence of the ESM1 protein, preferably over the entire length of the said ESM1 proteins, respectively.

[0051] The term “IGFBP7” as used herein refers to insulin like growth factor binding protein 7 encoded in humans by the IGFBP7 gene. Its major function is the regulation of availability of insulinlike growth factors (IGFs) in tissue as well as in modulating IGF binding to its receptors. It alsostimulates cell adhesion. In humans, two isoforms have been reported. Moreover, several orthologues have been reported in various animal species. The IGFBP7 protein referred to in accordance with the present invention is preferably human IGFBP7 having an amino acid sequence as deposited under UniProt accession number Q16270. It will be understood that the term IGFBP7 also relates to variants of said proteins. Such variants have at least the same essential biological and immunological properties if they are detectable by the same specific assays referred to in this specification. Moreover, it is to be understood that a variant as referred to in accordance with the present invention shall have an amino acid sequence which differs due to at least one amino acid substitution, deletion and / or addition wherein the amino acid sequence of the variant is still, preferably at least 50%, 60%, 70%, 80%, 85%, 90%, 92%, 95%, 97%, 98%, or 99% identical with the specific amino sequence of the IGFBP7 protein, preferably over the entire length of the said IGFBP7 proteins, respectively.

[0052] The term “GDF15” as used herein refers to growth differentiation factor 15 encoded in humans by the GDF15 gene. It is implicated in the regulation of inflammatory pathways, apoptosis, angiogenesis, cell repair and cell growth. Several orthologues have been re-ported in various animal species. The GDF15 referred to in accordance with the present invention is preferably human GDF15 having an amino acid sequence as deposited under UniProt accession number Q99988. It will be understood that the term GDF15 also relates to variants of said proteins. Such variants have at least the same essential biological and immunological properties if they are detectable by the same specific assays referred to in this specification. Moreover, it is to be understood that a variant as referred to in accordance with the present invention shall have an amino acid sequence which differs due to at least one amino acid substitution, deletion and / or addition wherein the amino acid sequence of the variant is still, preferably at least 50%, 60%, 70%, 80%, 85%, 90%, 92%, 95%, 97%, 98%, or 99% identical with the specific amino sequence of the GDF15, prefer-ably over the entire length of the said GDF15 proteins, respectively.

[0053] The term “IL-6” as used herein refers to interleukin 6 encoded in humans by the IL6 gene. IL-6 has a wide variety of biological functions in immunity, tissue regeneration and metabolism. Several orthologues have been reported in various animal species. The IL-6 referred to in accordance with the present invention is preferably human IL-6 having an amino acid sequence as deposited under UniProt accession number P05231. It will be understood that the term IL-6 also relates to variants of said proteins. Such variants have at least the same essential biological and immunological properties if they are detectable by the same specific assays referred to in this specification. Moreover, it is to be understood that a variant as referred to in accordance with the present invention shall have an amino acid sequence which differs due to at least one amino acid substitution, deletion and / or addition wherein the amino acid sequence of the variant is still, preferably at least 50%, 60%, 70%, 80%, 85%, 90%, 92%, 95%, 97%, 98%, or 99%identical with the specific amino sequence of the IL-6, preferably over the entire length of the said IL-6 proteins, respectively.

[0054] The term “ANG2” (also designated as ANGP2) as used herein refers to angiopoietin 2 encoded in humans by the ANGPT2 gene. It is upregulated in multiple inflammatory dis-eases and is implicated in the direct control of inflammation-related signaling pathways. In humans, three isoforms have been reported. Moreover, several orthologues have been reported in various animal species. The ANG2 referred to in accordance with the present invention is preferably human ANG2 having an amino acid sequence as deposited under UniProt accession number 015123. It will be understood that the term ANG2 also relates to variants of said proteins. Such variants have at least the same essential biological and immunological properties if they are detectable by the same specific assays referred to in this specification. Moreover, it is to be understood that a variant as referred to in accordance with the present invention shall have an amino acid sequence which differs due to at least one amino acid substitution, deletion and / or addition wherein the amino acid sequence of the variant is still, preferably at least 50%, 60%, 70%, 80%, 85%, 90%, 92%, 95%, 97%, 98%, or 99% identical with the specific amino sequence of the ANG2, preferably over the entire length of the said ANG2, respectively.

[0055] The term “C-terminal type VI (a3) collagen (PRO-C6)” as used herein refers to a collagen VI (Col6a3) fragment also called endotrophin. Preferably, Col6a3 in human has an amino acid sequence as shown in UniProt accession number P12111. It will be understood that the term PRO-C6 also relates to variants of said proteins. Such variants have at least the same essential biological and immunological properties if they are detectable by the same specific assays referred to in this specification. Moreover, it is to be understood that a variant as referred to in accordance with the present invention shall have an amino acid sequence which differs due to at least one amino acid substitution, deletion and / or addition wherein the amino acid sequence of the variant is still, preferably at least 50%, 60%, 70%, 80%, 85%, 90%, 92%, 95%, 97%, 98%, or 99% identical with the specific amino sequence of the PRO-C6, preferably over the entire length of the said PRO-C6, respectively.

[0056] The term “N-terminal type III collagen propeptide (PRO-C3)” as used herein refers to a fragment of collagen type III (Col3al). Preferably, Col3al in human has an amino acid sequence as shown in UniProt accession number P02461. It will be understood that the term PRO-C3 also relates to variants of said proteins. Such variants have at least the same essential biological and immunological properties if they are detectable by the same specific assays referred to in this specification. Moreover, it is to be understood that a variant as referred to in accordance with the present invention shall have an amino acid sequence which differs due to at least one amino acid substitution, deletion and / or addition wherein the amino acid sequence of the variant is still, preferably at least 50%, 60%, 70%, 80%, 85%, 90%, 92%, 95%, 97%,98%, or 99% identical with the specific amino sequence of the PRO-C3, preferably over the entire length of the said PRO-C3, respectively.

[0057] The physiological amount of a biomarker as referred to herein refers to the amount of the biomarker that can be found in a subject know to not suffer from a medical condition or disease or disorder referred to herein. An elevated amount for the biomarker in comparison to the physiological amount may be determined by comparing the determined amount to either a reference and, preferably, a reference amount for the biomarker, derived from a subj ect or group of subjects known not to suffer from the medical condition or disease or disorder referred to herein or by comparing the determined amount to either a reference and, preferably, a reference amount for the biomarker, derived from a subject or group of subjects known to suffer from the medical condition or disease or disorder referred to herein. In the latter case an identical or increased amount is indicative for the medical condition or disease or disorder, while in the first case, an increased amount is indicative for a medical condition or disease or disorder. Vice versa, in the latter case a reduced amount is indicative for the absence of the medical condition or disease or disorder, while in the first case for the aforementioned reference, an identical or decreased amount is also indicative for the absence of said medical condition or disease or disorder.

[0058] Advantageously, it has been found in the studies underlying the present invention that the biomarker BMP 10 shows excellent correlation to stages of heart valve diseases or disorders and, in particular, TR and reflects 2D echocardiography data which are cumbersome to generate and cost intensive. To quantify the severity of regurgitation and related tissue changes by ventricular and atrial changes by increased BMP 10 release, to use such information to quantify the progression of tissue changes (“remodeling“), the severity of the disease, the risk for rehospitalization, and to use the combined information to prognosticate the right time and kind of intervention (such as medical therapy, tricuspid valve repair or replacement) and predict its outcome (e.g., atrial and ventricular reverse remodeling), the amount of BMP 10 can be determined in a blood sample. Moreover, the method of the present invention is also suitable for assessing pulmonary hypertension and, in particular, determining the pre-capillary component of pulmonary hypertension. The latter information, combined to the above described information, can be used to prognosticate the right time of tricuspid valve repair or replacement and predict its outcome.

[0059] Thus, BMP 10 also serves as a biomarker for diseases or disorders associated with heart valve disease or disorders such as TR. In particular, right heart dysfunctions that are either caused by or causing the heart valve disease can be assessed in this context and risk stratification for patients with respect to various endpoints such as right heart failure, right atrial dilation, rightventricular dysfunction, and / or pulmonary hypertension or success rates of therapies, such as tricuspid replacement, can be provided.

[0060] Thereby, effective therapeutic measures can be selected at an early stage of disease development or progression. In particular, based on the studies underlying this invention one can derive that the progression of the tissue changes might not be reversible so that the biomarker information allows to prognosticate the optimum timing and success of a tricuspid valve repair or replacement.

[0061] Moreover, it has been found that BMP- 10 specifically correlates with right ventricular (RV) function and pulmonary vascular resistance (PVR), which are critical parameters for managing tricuspid regurgitation. As such, the studies underlying the present invention demonstrate a specific technical advantage that overcomes the limitations of current standard of care based on biomarkers such as NT-proBNP or type I procollagen (PICP) because the right ventricle tolerates volume overload differently than pressure overload and standard markers such as NT-proBNP are heavily influenced by Left Ventricular wall stress.

[0062] Furthermore, BMP- 10 provides superior staging capability for TR and RV dysfunction compared to other markers such as PICP. In particular, PICP is a marker of fibrosis, which is a downstream consequence of chronic disease. In contrast thereto, the studies underlying the present invention show that BMP- 10 levels correlate incrementally with the severity of TR (e.g. Figure 1). This offers a distinct diagnostic advantage compared to biomarkers such as PICP, which indicates active collagen synthesis (fibrosis), a non-specific reparative process found in many cardiac and non-cardiac conditions. As opposed thereto, BMP-10 is a cardiac-specific protein predominantly expressed in the right atrium (Wang et al. 2024). Its elevation in TR directly reflects the hemodynamic stretch of the right heart chambers caused by the regurgitant volume, providing a direct functional assessment rather than a secondary tissue marker like PICP.

[0063] All definitions and explanations of the terms made herein above apply mutatis mutandis to the following embodiments.

[0064] The present invention also relates to a computer-implemented method for assessing a heart valve disease or disorder in a subject comprising the steps of

[0065] a) receiving data for the amount of a BMPlO-type peptide in a sample of a subject in a processor;

[0066] b) comparing said data using the processor to reference data, preferably, stored on a storage medium; andc) assessing the heart valve disease or disorder in the subject based on the comparison.

[0067] Preferably, all steps of the computer-implemented method are performed by one or more processors as defined elsewhere herein of a computer or computer network.

[0068] The data for the amount of a BMP10-type peptide received in step (a) shall be derived from the determination of the amount of a BMP10-type peptide from a sample of a subject which shall be assessed as described elsewhere herein. Preferably, the data comprise a value for the total amount or concentration of a BMP10-type peptide in the sample. Typically, the value will be received by the processor by uploading or sending the data to the processor. Alternatively, the data can be received by the processor by inputting the data manually via a user interface.

[0069] More preferably, said data for the amount of a BMP10-type peptide in a sample are received from an analyzer capable of automatically determining the amount of a BMP10-type peptide present in a sample of the subject to be assessed.

[0070] Data for references (i.e. reference data) such as reference amounts referred to elsewhere herein are typically stored on a storage medium which is operatively linked to the processor. Thus, by acquiring the reference data from the storage medium, the processor is capable of making a comparison between the data for the amount of the BMP10-type peptide determined in the sample and the reference data comprising the reference amounts for the BMP10-type peptide useful for making the assessment as described elsewhere herein in detail.

[0071] The assessment of the heart valve disease or disorder may be made in the aforementioned method by the processor which, preferably, executes predefined and stored rules for making the assessment. Yet, artificial intelligence (AI) may be used as well for making the assessment or for strengthening the assessment. AI systems suitable in accordance with the present invention, typically, implement mathematical tools and models. Such tools and models are, preferably, Markov decision processes, dynamic decision networks, game theory, and / or mechanism design for decision analyses. Tools such as Bayesian network can be used to assist reasoning, learning, planning and perception in an Al system. Probabilistic algorithms may be used for filtering, prediction, smoothing, and / or finding explanations for data streams. Thereby, they help perception systems in analyzing processes that occur over time (e.g., hidden Markov models or Kalman filters). Other Al systems may involve artificial neural networks or deep learning networks. Al systems may also include large language models such as Generative pretrained transformer (GPT). It will be understood that the AI may be, preferably, trained using subjects or groups of subjects defined elsewhere herein for biomarker references.The assessment made by the processor may be provided via a suitable output device as described elsewhere herein in detail.

[0072] The present invention also relates to a device adapted for carrying out the method of the present invention comprising:

[0073] a) a detector for determining the amounts of a BMP10-type peptide in a sample of a subject; and

[0074] b) a processor which is adapted to compare the detected amount of the BMP10-type peptide to a reference for assessing a heart valve disease or disorder.

[0075] The term “device” as used herein refers to a system comprising the aforementioned elements operatively linked to each other as to allow the determination of the amount of a BMP10-type peptide in a sample of a subject and carrying out the comparison as well as establishing the assessment.

[0076] The detector, typically, comprises at least one detection zone being capable of detecting the BMP10-type peptide present in the sample. The detector may also comprise a reaction zone that allows carrying out a chemical detection reaction. Preferably, prior to introducing the sample into the detection zone, the sample may be contacted to detection agents in order to generated detectable signals, e.g., by allowing the formation of analyte-antibody complexes whereby the antibody as detection agents comprises a detectable label that can be detected by the detector in the detection zone. The detection zone shall be adapted to determine the amount of the biomarkers based on the presence, absence or intensity of detectable signals generated. The determined amount can be subsequently transmitted to the processor for making the comparison and, typically, also making the assessment.

[0077] The processor is adapted for carrying out the comparison of the determined amount of the BMP10-type peptide in the sample and the reference. Typically, it may run an implemented algorithm for doing so. The processor, typically, comprises a Central Processing Unit (CPU) and / or one or more Graphics Processing Units (GPUs) and / or one or more Application Specific Integrated Circuits (ASICs) and / or one or more Tensor Processing Units (TPUs) and / or one or more field-programmable gate arrays (FPGAs) or the like. A processor may, for example, be or may be included in a general purpose computer or a portable computing device. It should also be understood that multiple computing devices may be used together, e.g., over a network or other methods of transferring data, for per-forming one or more steps of the methods disclosed herein. Exemplary computing devices include desktop computers, laptop computers, personal data assistants (“PDA”), cellular devices, smart or mobile devices, tablet computers, servers, and the like. In general, a data processing element comprises a processor capable ofexecuting a plurality of instructions (such as a program of software). The processor, typically, comprises or has access to a memory. The memory, typically, comprises the stored reference to be used for the comparison. A memory is a computer readable medium and may comprise a single storage device or multiple storage devices, located either locally with the computing device or accessible to the computing device across a network, for example. Computer-readable media may be any available media that can be accessed by the computing device and includes both volatile and non-volatile media. Further, computer readable-media may be one or both of re-movable and non-removable media. By way of example, and not limitation, computer-readable media may comprise computer storage media. Exemplary computer storage media includes, but is not limited to, RAM, ROM, EEPROM, flash memory or any other memory technology, CD-ROM, Digital Versatile Disk (DVD) or other optical disk storage, magnetic cassettes, magnetic tape, magnetic disk storage or other magnetic storage devices, or any other medium which can be used for storing a plurality of instructions capable of being accessed by the computing device and executed by the processor of the computing device. The processor may also comprise or has access to an output device. Exemplary output devices include fax machines, displays, printers, and files, for example. According to some embodiments of the present disclosure, a computing device may perform one or more steps of a method disclosed herein, and thereafter provide an output, via an output device, relating to a result, indication, ratio or other factor of the method.

[0078] Yet, the invention contemplates a kit for carrying out the method of the present invention comprising a detection agent for a BMP10-type peptide in a sample of a subject.

[0079] The term “kit” as used herein refers to a collection of the aforementioned components, preferably, provided separately or within a single container. The container also comprises instructions for carrying out the method of the present invention. These instructions may be in the form of a manual or encoded by a readable bar code or may be provided by a computer program code, which is capable of carrying out the calculations and comparisons referred to in the methods of the present invention and to establish the assessment accordingly when implemented on a computer or a data processing device. The computer program code may be provided on a data storage medium or device such as an optical storage medium (e.g., a Compact Disc) or directly on a computer or data processing device. Moreover, the kit may, preferably, comprise standard amounts for the analyte to be detected for calibration purposes (i.e. calibrators).

[0080] The kit shall comprise at least one detection agent for a BMP10-type peptide. Yet, the kit may also preferably comprise at least one further detection agent for a biomarker selected from thegroup consisting of: a natriuretic peptide, MyBPC3, FGF23, ESMI, GDF15, IL-6, ANG2, PRO-CD6 or PRO-C3.

[0081] The term “detection agent” relates to an agent that comprises a binding moiety which specifically binds the analyte to be detected, i.e. the BMPlO-type peptide or any other biomarker referred to herein such as a biomarker selected from the group consisting of: A natriuretic peptide, MyBPC3, FGF23, ESMI, GDF15, IL-6, ANG2, PRO-CD6 or PRO-C3. Preferred detection agents referred to herein are antibodies, aptamers or engineered pep-tides, proteins or peptide nucleic acids (PNAs). Specific binding means that the detection agent has properties that allow for binding of the analyte but not to other molecules pre-sent in the sample under the conditions applied for carrying out the method of the invention.

[0082] Preferably, the detection agent in accordance with the present invention is an antibody. Antibodies as referred to herein may be monoclonal antibodies, polyclonal antibodies, multispecific antibodies (e.g., bispecific antibodies), and antibody fragments that exhibit the desired antigen-binding activity (i.e. an antigen-binding fragments thereof). Preferably, the antibody is a polyclonal antibody or an antigen-binding fragment thereof. More preferably, the antibody is a monoclonal antibody or an antigen-binding fragment thereof. Moreover, as described elsewhere herein, it is envisaged that two monoclonal antibodies are used that bind at different positions of the BMPlO-type peptide and, thus, can be used in a sandwich-format immunoassay.

[0083] Preferably, said kit comprises at least one further reagent selected form the group consisting of:

[0084] i) reagents for detecting the BMP 10-type peptide;

[0085] ii) calibrators for the BMP 10-type peptide;

[0086] iii) buffer solutions;

[0087] iv) solvents;

[0088] v) instructions for carrying out the method of the invention; and

[0089] vi) at least one further detection agent for a biomarker selected from the group consisting of: a natriuretic peptide, MyBPC3, FGF23, ESMI, GDF15, IL-6, ANG2, PR0-CD6 or PRO-C3.

[0090] Moreover, the invention provides, in general, for the use of a BMPlO-type peptide in a sample of a subject or a detection agent for a BMP10-type peptide to be applied in said sample for assessing a heart valve disease or disorder. Preferably, said assessing is assessing as referred to herein elsewhere. In particular, said assessing comprises staging of TR, comprises providing a recommendation for heart valve disease or disorder therapy, preferably, tricuspid valve repair or replacement, or is further comprises assessing right heart failure, right atrial dilation, right ventricular dysfunction, and / or pulmonary hypertension.The following are particular preferred embodiments of the present invention.

[0091] Embodiment 1: A method for assessing a heart valve disease or disorder comprising the steps of:

[0092] a) determining the amount of a BMP10-type peptide in a sample of said subject; and b) comparing the amount determined in step a) to a reference, whereby the heart valve disease or disorder is assessed.

[0093] Embodiment 2: The method of embodiment 1, wherein said heart valve disease or disorder is tricuspid regurgitation (TR).

[0094] Embodiment 3: The method of embodiment 2, wherein said assessing comprises staging of TR.

[0095] Embodiment 4: The method of any one of embodiments 1 to 3, wherein said reference is an amount for the BMP10-type peptide derived from a subject or group of subjects known to exhibit the heart valve disease or disorder.

[0096] Embodiment 5: The method of embodiment 4, wherein an amount for the BMP10-type peptide determined in the sample of the subject being essentially identical or increased compared to the reference is indicative for a subject suffering from the heart valve disease or disorder or suffering from a more advanced stage of the heart valve disease or disorder, whereas an amount for the BMPlO-type peptide determined in the sample of the subject being decreased compared to the reference is indicative for a subject which is not suffering from the heart valve disease or disorder or suffering from a less advanced stage of the heart valve disease or disorder.

[0097] Embodiment 6: The method of any one of embodiments 1 to 3, wherein said reference is an amount for the BMP10-type peptide derived from a subject or group of subjects known not to exhibit the heart valve disease or disorder.

[0098] Embodiment 7: The method of embodiment 6, wherein an amount for the BMP10-type peptide determined in the sample of the subject being essentially identical or decreased compared to the reference is indicative for a subject which is not suffering from the heart valve disease or disorder, whereas an amount for the BMP10-type peptide determined in the sample of the subject being increased compared to the reference is indicative for a subject at risk or suffering from the heart valve disease or disorder.Embodiment 8: The method of any one of embodiment 1 to 7, wherein said assessing comprises providing a recommendation for heart valve disease or disorder therapy, preferably, tricuspid valve repair or replacement.

[0099] Embodiment 9: The method of any one of embodiments 1 to 8, wherein said assessing comprises predicting or monitoring the outcome of a heart valve disease or disorder therapy, preferably, tricuspid repair or replacement.

[0100] Embodiment 10: The method of any one of embodiments 1 to 9, wherein said assessing the heart valve disease or disorder further comprises assessing right heart failure, right atrial dilation, right ventricular dysfunction, and / or pulmonary hypertension.

[0101] Embodiment 11: The method of any one of embodiments 1 to 10, wherein said sample is a body fluid sample, preferably, a whole blood, serum or plasma sample.

[0102] Embodiment 12: The method of any one of embodiments 1 to 11, wherein said subject is a mammal, preferably, a human.

[0103] Embodiment 13: The method of embodiment 12, wherein said subject does not exhibit right ventricular dysfunction and / or an increase of pulmonary vascular resistance and / or is asymptomatic despite significant TR.

[0104] Embodiment 14: The method of any one of embodiments 1 to 13, further comprising determining the amount of at least one further biomarkers selected from the group consisting of: a natriuretic peptide, preferably, N-terminal propeptide of B-type natriuretic peptide (NT-proBNP), myosin-binding protein C cardiac-type (MyBPC3), fibroblast growth factor 23 (FGF23), endothelial cell specific molecule 1 (ESM1), insulin like growth factor binding protein 7 (IGFBP7), growth differentiation factor 15 (GDF15), interleukin 6 (IL-6), angiopoietin 2 (ANG2), C-terminal fragment of type VI (a3) collagen (PRO-C6), and N-terminal type III collagen propeptide (PRO-C3).

[0105] Embodiment 15: The method of any one of embodiments 1 to 14, wherein step b) of said method is computer-implemented.

[0106] Embodiment 16: A computer-implemented method for assessing a heart valve disease or disorder in a subject comprising the steps of

[0107] a) receiving data for the amount of a BMPlO-type peptide in a sample of a subject in a processor;b) comparing said data using the processor to reference data, preferably, stored on a storage medium; and

[0108] c) assessing the heart valve disease or disorder in the subject based on the comparison.

[0109] Embodiment 17: A device adapted for carrying out the method of any one of embodiments 1 to 16 comprising:

[0110] a) a detector for determining the amounts of a BMP10-type peptide in a sample of a subject;

[0111] and

[0112] b) a processor which is adapted to compare the detected amount of the BMP 10-type peptide to a reference for assessing a heart valve disease or disorder.

[0113] Embodiment 18: A kit for carrying out the method of any one of embodiments 1 to 15 comprising a detection agent for a BMP10-type peptide in a sample of a subject.

[0114] Embodiment 19: The kit of embodiment 18, wherein said kit comprises at least one further reagent selected form the group consisting of:

[0115] i) reagents for detecting the BMP 10-type peptide;

[0116] ii) calibrators for the BMP 10-type peptide;

[0117] iii) buffer solutions;

[0118] iv) solvents;

[0119] v) instructions for carrying out the method of any one of embodiments 1 to 15; and vi) at least one further detection agent for a biomarker selected from the group consisting of: a natriuretic peptide, MyBPC3, FGF23, ESMI, GDF15, IL-6, ANG2, PRO-CD6 or PRO-C3.

[0120] Embodiment 20: Use of a BMPlO-type peptide in a sample of a subject or a detection agent for a BMP10-type peptide to be applied in said sample for assessing a heart valve disease or disorder.

[0121] All references cited throughout this specification are herewith incorporated by reference with respect to the specifically mentioned disclosure content as well as in their entireties.FIGURES

[0122] Figure 1. Boxplots of biomarkers across different TR regurgitation grades. The x-axis categorizes the different grades of TR regurgitation, ranging from no TR to minimal to severe. The y-axis indicates the levels of the biomarkers being measured. BMP 10 levels increase with the severity of TR regurgitation.

[0123] Figure 2. Boxplots of BMP10 levels in patients with and without Right Atrial (RA) Dilation reflecting progression of atrial remodelling and related tissue changes. This figure presents boxplots comparing the levels of BMP10 in patients with and without right atrial (RA) dilation. The x-axis distinguishes between the two patient groups: those with RA dilation and those without. The y-axis represents the BMP 10 levels measured in the patients. Patients with RA dilation have higher values of BMP10.

[0124] Figure 3. Boxplots of BMP10 levels in patients with reduced and normal Right Ventricular (RV) global function reflecting progression of ventricular remodelling and related tissue changes. This figure presents boxplots comparing the levels of BMP10 in patients with normal or reduced RV global function. The x-axis distinguishes between the two patient groups: those with normal RV global function and those restricted. The y-axis represents the BMP 10 levels measured in the patients. Patients with normal RV global function have lower BMP 10 values compared to patients with reduced RV global function.

[0125] Figure 4. Kaplan-Meier survival curves. This figure presents a Kaplan-Meier survival curve, which illustrates the proportion of patients having a re-hospitalisation due to CHF event over a specified period. The x-axis represents time (in years), while the y-axis shows the survival / re-hospitalization probability, ranging from 0 to 1. Censoring is indicated by tick marks or vertical lines on the curve, representing patients who were lost to follow-up or withdrew from the study before experiencing the event of interest.

[0126] Figure 5: Boxplots of BMP10 and the symptom weight gain of the patients. This figure presents boxplots comparing the levels of BMP 10 in patients with and without weight gain. The x-axis distinguishes between the two patient groups: those with and those without weight gain. The y-axis represents the BMP 10 levels measured in the patients. Patients with weight gain have higher BMP 10 values.

[0127] Figure 6: Boxplots of BMP10 and disease history of the patients. This figure presents boxplots comparing the levels of BMP10 in patients with and without a certain disease history. The x-axis distinguishes between the two patient groups: those with and those without disease history. The y-axis represents the BMP 10 levels measured in the patients.Figure 7. Scatterplot for TAPSE vs. BMP10. This figure presents a scatterplot depicting the relationship between Tricuspid Annular Plane Systolic Excursion (TAPSE) and BMP10 levels in the 70 patients for whom both measurements are available. The Pearson correlation between the two parameters is -0.412. X-Axis: Represents TAPSE values, which measure the systolic function of the right ventricle. Higher TAPSE values indicate better right ventricular function. Y-Axis: Represents BMP10 levels (log transformed), a biomarker measured in the blood. Each point on the scatterplot corresponds to an individual patient. The plot allows for visual assessment of the correlation between TAPSE and BMP10 levels. Trend Line: indicates the overall direction and strength of the relationship between TAPSE and BMP 10 values.

[0128] Figure 8. Scatterplot for right atrial area vs. BMP10. This figure presents a scatterplot depicting the relationship between right atrial area and BMP 10 levels in the 32 patients for whom both measurements are available. The Pearson correlation between the two parameters is 0.32. X-Axis: Represents the right atrial area. Y-Axis: Represents BMP10 levels (log transformed), a biomarker measured in the blood. Each point on the scatterplot corresponds to an individual patient. The plot allows for visual assessment of the correlation between right atrial area and BMP 10 levels. Trend Line: indicates the overall direction and strength of the relationship between right atrial area and BMP 10 values.

[0129] Figure 9: Scatterplot for right ventricle area vs. BMP10. This figure presents a scatterplot depicting the relationship between right ventricle area and BMP 10 levels in the 25 patients for whom both measurements are available. The Pearson correlation between the two parameters is 0.399. X-Axis: Represents the right ventricle area. Y-Axis: Represents BMP10 levels (log transformed), a biomarker measured in the blood. Each point on the scatterplot corresponds to an individual patient. The plot allows for visual assessment of the correlation between right ventricle end-diastolic area and BMP10 levels. Trend Line: indicates the overall direction and strength of the relationship between right ventricle end-diastolic area and BMP 10 values.

[0130] Figure 10: Scatterplot for Pulmonary-vascular resistance vs. BMP10. This figure presents a scatterplot depicting the relationship between pulmonary -vascular resistance and BMP 10 levels in the 131 patients for whom both measurements are available. The Pearson correlation between the two parameters is 0.467. X-Axis: Represents the pulmonary-vascular resistance. Y-Axis: Represents BMP10 levels (log transformed), a biomarker measured in the blood. Each point on the scatterplot corresponds to an individual patient. The plot allows for visual assessment of the correlation between Pulmonary-vascular resistance and BMP10 levels. Trend Line: indicates the overall direction and strength of the relationship between Pulmonary-vascular resistance and BMP10 values.EXAMPLES

[0131] The following Examples shall illustrate the invention. They shall, however, not be construed as limiting the scope of the invention.

[0132] Example 1: BMP10 as a biomarker for TR staging

[0133] Patients presenting with acute dyspnea to the Emergency Department were selected. For a total of 330 patients an echocardiography was performed within 10 days before or 3 days after the study inclusion, allowing the assessment of different grades of TR regurgitation.

[0134] Different biomarkers hsTNT, NT-proBNP, MYBPC3 and BMP 10 were determined in whole blood samples of the patients by using commercial tests. The results are shown in Fig. 1. BMP 10 levels significantly correlated best with the different stages of TR as found by echocardiography, i.e. no, minimal, mild, moderate and severe.

[0135] Example 2: BMP10 as a biomarker for atrial remodeling and right ventricular function

[0136] The levels of BMP 10 in patients with normal or reduced right ventricular global function within the analyzed cohort were compared. Fig. 2 shows that patients with normal right ventricular global function have significantly lower BMP 10 values compared to patients with reduced right ventricular global function.

[0137] Fig. 3 shows boxplots of BMP 10 levels in patients with reduced and normal Right Ventricular (RV) global function reflecting progression of ventricular re-modelling and related tissue changes.

[0138] Example 3: Predictive power of BMP10 for re-hospitalization, weight gain or medical history

[0139] To evaluate the predictive power of BMP 10 for re-hospitalization, we first assess the performance of a simple clinical model. This model included basic clinical variables such as age and diagnosis of heart failure (HF).

[0140] Subsequently, this clinical model was augmented by adding BMP 10 to determine if the biomarker provides additional predictive value on top of the established clinical factors. Theclinical model has an C-Index of 0.7319. By adding BMP10, an C-Index of 0.7686 could be achieved (see Fig. 4). A higher BMP10 value indicates a higher risk of having a rehospitalization (Hazard ratio = 1.18, see table below).

[0141] Table: Coefficients of the clinical model + Biomarker. The column “exp.coef ’ represents the Hazard ratio.

[0142] Swnmary staUstfcs of model including LabejBM IQJJIi and GSO_HF and Age results in a C-Index o( 0.769 ( 0.7393 - 0,7979 ) coat exp coef. se.coef. P. Value W67A g / <<^ cm 1,®5 7.02 0.27 0.00 <01; 7 EiccilE Ail I / / / / / / / / / / / / liSOI;<.29i

[0143]

[0144] The box plot analyses presented in Fig. 5 and Fig. 6 showed that increased BMP 10 levels in the investigated cohort were also associated with weight gain. Moreover, there was an association with the disease history of the patient. Increased levels of BMP10 were found in patients that suffered from / were subjected to: stent treatment, coronary artery bypass graft (CABG), valve replacement, heart failure, hypertensive heart disease, use of peace makers (ICD CRT), atrial fibrillation, and / or stroke.

[0145] Example 4: BMP10 and pulmonary arterial hypertension (PAH)

[0146] Patients undergoing RHC within a prospective, single-center, cross-sectional study were investigated. For in total 84 patients the ECHO assessment was within + / - 14 days of the blood draw. For Tricuspid annular motion (TAPSE), 70 patients with ECHO value and BMP 10 value were investigated.

[0147] The results are shown in Figs. 7 to 10. The trend line in Fig. 7 indicates the overall direction and strength of the relationship between TAPSE and BMP 10 values. The trend line indicates the overall direction and strength of the relationship between right atrial area and BMP 10 values. The trend line in Fig. 9 indicates the overall direction and strength of the relationship between right ventricle end-diastolic area and BMP 10 values. The trend line in Fig. 10 indicates the overall direction and strength of the relationship between Pulmonary-vascular resistance and BMP 10 values.

Claims

Claims1. A method for assessing a heart valve disease or disorder comprising the steps of:a) determining the amount of a BMP10-type peptide in a sample of said subject; andb) comparing the amount determined in step a) to a reference, whereby the heart valve disease or disorder is assessed.

2. The method of claim 1, wherein said heart valve disease or disorder is tricuspid regurgitation (TR).

3. The method of claim 2, wherein said assessing comprises staging of TR.

4. The method of any one of claims 1 to 3, wherein said reference is an amount for the BMP10-type peptide derived from a subject or group of subjects known to exhibit the heart valve disease or disorder.

5. The method of claim 4, wherein an amount for the BMP10-type peptide determined in the sample of the subject being essentially identical or increased compared to the reference is indicative for a subject suffering from the heart valve disease or disorder or suffering from a more advanced stage of the heart valve disease or disorder, whereas an amount for the BMPlO-type peptide determined in the sample of the subject being decreased compared to the reference is indicative for a subject which is not suffering from the heart valve disease or disorder or suffering from a less advanced stage of the heart valve disease or disorder.

6. The method of any one of claims 1 to 3, wherein said reference is an amount for the BMP10-type peptide derived from a subject or group of subjects known not to exhibit the heart valve disease or disorder.

7. The method of claim 6, wherein an amount for the BMP10-type peptide determined in the sample of the subject being essentially identical or decreased compared to the reference is indicative for a subject which is not suffering from the heart valve disease or disorder,whereas an amount for the BMP10-type peptide determined in the sample of the subject being increased compared to the reference is indicative for a subject at risk or suffering from the heart valve disease or disorder.

8. The method of any one of claims 1 to 7, wherein said assessing comprises providing a recommendation for heart valve disease or disorder therapy, preferably, tricuspid valve repair or replacement.

9. The method of any one of claims 1 to 8, wherein said assessing comprises predicting or monitoring the outcome of a heart valve disease or disorder therapy, preferably, tricuspid repair or replacement.

10. The method of any one of claims 1 to 9, wherein said assessing the heart valve disease or disorder further comprises assessing right heart failure, right atrial dilation, right ventricular dysfunction, and / or pulmonary hypertension.

11. The method of any one of claims 1 to 10, further comprising determining the amount of at least one further biomarkers selected from the group consisting of: a natriuretic peptide, preferably, N-terminal propeptide of B-type natriuretic peptide (NT -proBNP), myosin-binding protein C cardiac-type (MyBPC3), fibroblast growth factor 23 (FGF23), endothelial cell specific molecule 1 (ESM1), insulin like growth factor binding protein 7 (IGFBP7), growth differentiation factor 15 (GDF15), interleukin 6 (IL-6), angiopoietin 2 (ANG2), C-terminal fragment of type VI (a3) collagen (PRO- C6), and N-terminal type III collagen propeptide (PRO-C3).

12. A computer-implemented method for assessing a heart valve disease or disorder in a subject comprising the steps ofa) receiving data for the amount of a BMPlO-type peptide in a sample of a subject in a processor;b) comparing said data using the processor to reference data, preferably, stored on a storage medium; andc) assessing the heart valve disease or disorder in the subject based on the comparison.

13. A device adapted for carrying out the method of any one of claims 1 to 12 comprising:a) a detector for determining the amounts of a BMP10-type peptide in a sample of a subject; andb) a processor which is adapted to compare the detected amount of the BMP10-type peptide to a reference for assessing a heart valve disease or disorder.

14. A kit for carrying out the method of any one of claims 1 to 12 comprising a detection agent for a BMP10-type peptide in a sample of a subject.

15. Use of a BMP10-type peptide in a sample of a subject or a detection agent for a BMP10-type peptide to be applied in said sample for assessing a heart valve disease or disorder.

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