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Goodwill and Intangible Assets | 3 Months Ended
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Mar. 31, 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 three-month period ended March 31, 2019 were as follows (in thousands):
| 2019
Goodwill balance at January 1 | $ | 335,433 |
Effect of foreign exchange | (413 | )
Purchase price adjustments as the result of acquisitions | (69 | )
Goodwill balance at March 31 | $ | 334,951 |
Total accumulated goodwill impairment losses aggregated to approximately $8.3 million as of March 31, 2019 and December 31, 2018. We did not have any goodwill impairments for the three-month periods ended March 31, 2019 and 2018. The total goodwill balance as of March 31, 2019 and December 31, 2018, was related to our cardiovascular segment. Other intangible assets at March 31, 2019 and December 31, 2018, consisted of the following (in thousands):
| March 31, 2019
| Gross Carrying Amount |  | Accumulated Amortization |  | Net Carrying Amount
Patents | $ | 20,231 |  |  | $ | (5,467 | ) |  | $ | 14,764 |
Distribution agreements | 8,012 |  |  | (6,023 | ) |  | 1,989 |
License agreements | 26,926 |  |  | (7,941 | ) |  | 18,985 |
Trademarks | 29,991 |  |  | (7,298 | ) |  | 22,693 |
Covenants not to compete | 1,028 |  |  | (1,008 | ) |  | 20 |
Customer lists | 39,965 |  |  | (24,732 | ) |  | 15,233 |
In-process technology | 3,420 |  |  | — |  |  | 3,420 |
Total | $ | 129,573 |  |  | $ | (52,469 | ) |  | $ | 77,104 |
| 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-month periods ended March 31, 2019 and 2018 was approximately $14.8 million and $8.5 million, respectively. Estimated amortization expense for the developed technology and other intangible assets for the next five years consists of the following as of March 31, 2019 (in thousands):
Year Ending December 31 |
Remaining 2019 | $ | 44,351 |
2020 | 56,238 |
2021 | 48,864 |
2022 | 47,398 |
2023 | 46,136 |

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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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