Background Catheter ablation of premature ventricular complexes from aortic sinus cusps (ASC‐PVC) is a complex procedure that conventionally requires coronary catheterization (CC) to localize coronary artery ostium (CAO). Little published information is available on the mapping and ablation with zero‐fluoroscopy (ZF) of ASC‐PVC. The aim of the study was to determine the efficacy and safety of ASC‐PVC ablation with a ZF approach guided by 3D intracardiac echocardiography integration in the electroanatomical mapping system (ICE 3D‐EAM). Methods This observational study included one patient cohort treated conventionally and another treated with ICE 3D‐EAM‐guided ZF ablation. Clinical, efficacy, and safety outcomes were evaluated acutely and at 3 months follow‐up. Results The study included 21 patients with ASC‐PVC: 10 in the ZF group (age 49 ± 16 years, 60% males) and 11 in the control group (age 47 ± 15 years, 27% males). Fluoroscopy was not required for any patient in the ZF group. Acute success was obtained in 80% of the ZF group vs 55% of the control group (P = .36). The recurrence rate was 30% in the ZF group vs 27% in the control group (P = 1). One nonsevere complication was observed in the ZF group (P = .48). Conclusions ZF catheter ablation of ASC‐PVC guided by ICE 3D‐EAM is feasible, effective, and safe. The graphical shows the workflow for ZF ablation approach of ASC‐PVC using ICE 3D‐EAM. The key point is the ICE 3D‐EAM reconstruction which allows to assess the distance of the ablation catheter tip to CAO. Note that if the distance is at least >5 mm from earliest LVAT to CAO, the ablation is started. On the other hand, with a distance <5 mm respect to CAO, the ablation is not performed and another safe adjacent site is searched. ZF: zero‐fluoroscopy. ASC: Aortic sinus cusp. PVC: Premature ventricular complex. LV: Left ventricle. RV: Right ventricle. CAO: Coronary artery ostium. LVAT: Local ventricular activation time. ICE 3D‐EAM: Electroanatomic reconstruction guided by intracardiac echocardiography.