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Goodwill and Intangible Assets
 6 Months Ended
Jun. 30, 2019
Goodwill and Intangible Assets Disclosure [Abstract]  
Goodwill and Intangible Assets Goodwill and Intangible Assets. The changes in the carrying amount of goodwill for the six-month period ended June 30, 2019 were as follows (in thousands):
 
2019
Goodwill balance at January 1
$
335,433

Effect of foreign exchange
(181
)
Additions and adjustments as the result of acquisitions
16,881

Goodwill balance at June 30
$
352,133



Total accumulated goodwill impairment losses aggregated to approximately $8.3 million as of June 30, 2019 and December 31, 2018. We did not have any goodwill impairments for the six-month periods ended June 30, 2019 and 2018. The total goodwill balance as of June 30, 2019 and December 31, 2018, was related to our cardiovascular segment.
Other intangible assets at June 30, 2019 and December 31, 2018, consisted of the following (in thousands):
 
June 30, 2019
 
Gross Carrying
Amount
 
Accumulated
Amortization
 
Net Carrying
Amount
Patents
$
20,985

 
$
(5,850
)
 
$
15,135

Distribution agreements
8,012

 
(6,280
)
 
1,732

License agreements
27,008

 
(9,016
)
 
17,992

Trademarks
30,246

 
(8,035
)
 
22,211

Covenants not to compete
1,028

 
(1,016
)
 
12

Customer lists
40,009

 
(26,092
)
 
13,917

In-process technology
3,420

 
—

 
3,420

 
 
 
 
 
 
Total
$
130,708

 
$
(56,289
)
 
$
74,419


 
December 31, 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



Aggregate amortization expense for the three and six-month periods ended June 30, 2019 was approximately $14.9 million and $29.7 million, respectively. Aggregate amortization expense for the three and six-month periods ended June 30, 2018 was approximately $10.4 million and $18.9 million, respectively.

During the three months ended June 30, 2019 we recorded an impairment charge of $548,000 for the discontinuation of our product associated with the assets acquired in our June 2017 acquisition of patent rights and other intellectual property related to the Repositionable Chest Tube and related devices from Lazarus Medical Technologies, LLC. We did not record any impairment charges during the three and six months ended June 30, 2018.
Estimated amortization expense for the developed technology and other intangible assets for the next five years consists of the following as of June 30, 2019 (in thousands):

Year Ending December 31
 
Remaining 2019
$
30,817

2020
58,907

2021
51,550

2022
50,129

2023
48,830