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Goodwill and Intangible Assets | 12 Months Ended
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Dec. 31, 2019
Goodwill and Intangible Assets Disclosure [Abstract] |
Goodwill and Intangible Assets | 5.GOODWILL AND INTANGIBLE ASSETS The changes in the carrying amount of goodwill for the years ended December 31, 2019 and 2018, are as follows (in thousands):
​ | ​ | ​ | ​ | ​ | ​ | ​
​ |  | 2019 |  | 2018
Goodwill balance at January 1 | ​ | $ | 335,433 | ​ | $ | 238,147
Effect of foreign exchange | ​ |  | (199) | ​ |  | (1,304)
Additions and adjustments as the result of acquisitions | ​ |  | 17,959 | ​ |  | 98,590
Goodwill balance at December 31 | ​ | $ | 353,193 | ​ | $ | 335,433
​ Total accumulated goodwill impairment losses aggregated to $8.3 million as of December 31, 2019 and 2018. We did not have any goodwill impairments for the years ended December 31, 2019, 2018 and 2017. The total goodwill balance as of December 31, 2019 and 2018, is related to our cardiovascular segment. Other intangible assets at December 31, 2019 and 2018, consisted of the following (in thousands):
​ | ​ | ​ | ​ | ​ | ​ | ​ | ​ | ​ | ​
​ | ​ | December 31, 2019
​ | ​ | Gross Carrying | ​ | Accumulated | ​ | Net Carrying
​ |  | Amount |  | Amortization |  | Amount
Patents | ​ | $ | 22,703 | ​ | $ | (6,863) | ​ | $ | 15,840
Distribution agreements | ​ |  | 8,012 | ​ |  | (6,794) | ​ |  | 1,218
License agreements | ​ |  | 26,987 | ​ |  | (12,746) | ​ |  | 14,241
Trademarks | ​ |  | 30,240 | ​ |  | (9,477) | ​ |  | 20,763
Covenants not to compete | ​ |  | 964 | ​ |  | (964) | ​ |  | —
Customer lists | ​ |  | 39,984 | ​ |  | (28,763) | ​ |  | 11,221
In-process technology | ​ |  | 2,500 | ​ |  | — | ​ |  | 2,500
​ | ​ | ​ | ​ | ​ | ​ | ​ | ​ | ​ | ​
Total | ​ | $ | 131,390 | ​ | $ | (65,607) | ​ | $ | 65,783
​
​ | ​ | ​ | ​ | ​ | ​ | ​ | ​ | ​ | ​
​ | ​ | December 31, 2018
​ | ​ | Gross Carrying | ​ | Accumulated | ​ | Net Carrying
​ |  | Amount |  | Amortization |  | 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 years ended December 31, 2019, 2018 and 2017 was approximately $60.7 million, $41.2 million and $26.8 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. We identified indicators of impairment associated with certain acquired intangible assets based on our qualitative assessment, which required us to complete an interim quantitative impairment assessment. The primary indicator of impairment was slower than anticipated sales growth in the acquired products and uncertainty about future product development and commercialization associated with the acquired technologies. During the year ended December 31, 2019, we recorded impairment charges related to our amortizing intangible assets of approximately $869,000 from our July 2015 acquisition of certain assets from Distal Access, LLC, $548,000 from our June 2017 acquisition of certain assets from Lazarus Medical Technologies, LLC, and $1.8 million from our July 2017 acquisition of certain assets from Pleuratech ApS for a total of approximately $3.3 million. 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. The impairment charges recorded in 2019, 2018, and 2017 all pertained to our cardiovascular segment. Estimated amortization expense for the developed technology and other intangible assets for the next five years consists of the following as of December 31, 2019 (in thousands):
​ | ​ | ​ | ​
Year Ending December 31, | ​ | Estimated Amortization Expense
2020 | ​ | $ | 59,386
2021 | ​ |  | 52,032
2022 | ​ |  | 50,682
2023 | ​ | ​ | 49,485
2024 | ​ |  | 46,506
​

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