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Goodwill and Intangible Assets | 12 Months Ended
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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 no t 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 |

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- Definition The entire disclosure for goodwill and intangible assets. + References Reference 1: http://fasb.org/us-gaap/role/ref/legacyRef -Publisher FASB -Name Accounting Standards Codification -Topic 350 -URI http://asc.fasb.org/topic&trid=2144416 + Details
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