Methods and devices are disclosed for the formation of a communication between the aorta and left atrium. The method includes introducing a puncturing device, positioning the device at a location along the aorta, and advancing the puncturing device to create a pathway. The method may include: a. via an inferior artery, advancing a perforating tip of the puncturing device towards the aorta; b. positioning the perforating tip adjacent a wall of the aorta, proximate the left atrium; and c. advancing the perforating tip to perforate through the wall of the aorta and then through a wall of the left atrium, to create a pathway between the aorta and the left atrium, wherein the creation of the pathway can be confirmed with at least one of fluoroscopy, electro-anatomical mapping, pressure measurement, contrast injection, and echocardiograph.