© 2019 Wiley Periodicals, Inc. The major sites of origins of idiopathic ventricular arrhythmias have been elucidated. Idiopathic ventricular arrhythmias most often present as premature ventricular contractions (PVCs) with a focal mechanism, and commonly occur without structural heart disease. Idiopathic ventricular arrhythmias usually originate from specific anatomical structures, commonly endocardial but sometimes epicardial and exhibit characteristic electrocardiograms (ECGs) based on their anatomical background. There are general and specific ECG characteristics that can localize the site of idiopathic PVC origins. The general ECG characteristics include the bundle branch block pattern, axis, QRS polarity in lead V6, QRS duration, precordial transition, maximal deflection index, and so forth. They can roughly localize the site of idiopathic PVC origins. Several major sites of idiopathic PVC origins are located close to each other, and specific ECG characteristics are helpful for localizing the site of origins more accurately in those PVCs. Twelve-lead surface ECG algorithms usually can localize the site of idiopathic PVC origins with a high accuracy, but their accuracy can be limited by the patients’ physique, heart rotation, specific conduction properties, presence of structural heart disease, and so forth. This review describes an overview of the approaches to the 12-lead surface ECG localization of idiopathic PVCs, and also discusses their caveats and limitations.