A quarter of coronary arteriovenous fistulas may present aneurysmal dilatation; however, spontaneous rupture of the aneurysm is rare. We present a rare case of ruptured coronary artery aneurysm (CAA) associated with coronary fistulas that presented cardiac tamponade. Subsequent to pericardial drainage, surgical repair of the CAA associated with coronary fistulas was performed electively. The aneurysm was located on the left anterior aspect of the pulmonary artery trunk. It communicated with both the left and right coronary arteries by anomalous fistulous vessels that drained into the pulmonary artery trunk. The feeding arteries and fistulous opening were ligated and closed, respectively, from within the aneurysm. Intraoperative fluorescence imaging was performed pre- and postoperatively to ensure no residual coronary fistulas were present. Although the rupture of CAA associated with coronary fistulas is rare, it should be considered as one of the potential causes of acute cardiac tamponade.