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Goodwill and Intangible Assets
 12 Months Ended
Dec. 31, 2018
Goodwill and Intangible Assets Disclosure [Abstract]  
Goodwill and Intangible Assets GOODWILL AND INTANGIBLE ASSETS

The changes in the carrying amount of goodwill for the years ended December 31, 2018 and 2017, are as follows (in thousands):
 
2018
 
2017
Goodwill balance at January 1
$
238,147

 
$
211,927

Effect of foreign exchange
(1,304
)
 
2,641

Additions as the result of acquisitions
98,590

 
23,579

Goodwill balance at December 31
$
335,433

 
$
238,147



Total accumulated goodwill impairment losses aggregated to $8.3 million as of December 31, 2018 and 2017. We did not have any goodwill impairments for the years ended December 31, 2018, 2017 and 2016. The total goodwill balance as of December 31, 2018 and 2017, is related to our cardiovascular segment.

Other intangible assets at December 31, 2018 and 2017, consisted of the following (in thousands):
 
2018
 
Gross Carrying
Amount
 
Accumulated
Amortization
 
Net Carrying
Amount
Patents
$
19,378

 
$
(5,012
)
 
$
14,366

Distribution agreements
8,012

 
(5,766
)
 
2,246

License agreements
26,930

 
(7,411
)
 
19,519

Trademarks
29,998

 
(6,586
)
 
23,412

Covenants not to compete
1,028

 
(1,000
)
 
28

Customer lists
39,936

 
(23,361
)
 
16,575

In-process technology
3,420

 
—

 
3,420

 
 
 
 
 
 
Total
$
128,702

 
$
(49,136
)
 
$
79,566


 
2017
 
Gross Carrying
Amount
 
Accumulated
Amortization
 
Net Carrying
Amount
Patents
$
16,528

 
$
(3,737
)
 
$
12,791

Distribution agreements
7,262

 
(4,686
)
 
2,576

License agreements
23,783

 
(5,568
)
 
18,215

Trademarks
16,224

 
(4,686
)
 
11,538

Covenants not to compete
1,028

 
(968
)
 
60

Customer lists
31,935

 
(18,482
)
 
13,453

In-process technology
920

 
—

 
920

 
 
 
 
 
 
Total
$
97,680

 
$
(38,127
)
 
$
59,553



Aggregate amortization expense for the years ended December 31, 2018, 2017 and 2016 was approximately $41.2 million, $26.8 million and $19.3 million, respectively.

We evaluate long-lived assets, including amortizing intangible assets, for impairment whenever events or changes in circumstances indicate that their carrying amounts may not be recoverable. We perform the impairment analysis at the asset group for which the lowest level of identifiable cash flows are largely independent of the cash flows of other assets and liabilities. We compare the carrying value of the amortizing intangible assets acquired to the undiscounted cash flows expected to result from the asset group and determine whether the carrying amount is recoverable. We determine the fair value of our amortizing assets based on estimated future cash flows discounted back to their present value using a discount rate that reflects the risk profiles of the underlying activities. During the years ended December 31, 2018 and 2017, we recorded impairment charges of $657,000, related to our July 2015 acquisition of certain assets from Quellent, LLC, and $809,000, related to our July 2015 acquisition of certain assets from Distal Access, LLC, respectively, all of which pertained to our cardiovascular segment. Some of the factors that influenced our estimated cash flows were slower than anticipated sales growth in the products acquired from our Quellent and Distal Access acquisitions and uncertainty about future sales growth. We did not record any impairment charges during the year ended December 31, 2016.

Estimated amortization expense for the developed technology and other intangible assets for the next five years consists of the following as of December 31, 2018 (in thousands):
Year Ending December 31
 
2019
$
58,035

2020
55,341

2021
48,084

2022
46,648

2023
45,417