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Goodwill and Intangible Assets | 9 Months Ended
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Sep. 30, 2020
Goodwill and Intangible Assets Disclosure [Abstract] |
Goodwill and Intangible Assets | 6. Goodwill and Intangible Assets. The changes in the carrying amount of goodwill for the nine-month period ended September 30, 2020 were as follows (in thousands): ​
​ | ​ | ​ | ​
​ |  | 2020
Goodwill balance at January 1 | ​ | $ | 353,193
Effect of foreign exchange | ​ |  | 314
Additions and adjustments as the result of acquisitions | ​ |  | 115
Goodwill balance at September 30 | ​ | $ | 353,622
​ Total accumulated goodwill impairment losses aggregated to approximately $8.3 million as of September 30, 2020 and December 31, 2019. We did not have any goodwill impairments for the nine-month periods ended September 30, 2020 and 2019. The total goodwill balance as of September 30, 2020 and December 31, 2019 was related to our cardiovascular segment. ​ Other intangible assets at September 30, 2020 and December 31, 2019 consisted of the following (in thousands): ​
​ | ​ | ​ | ​ | ​ | ​ | ​ | ​ | ​ | ​
​ | ​ | September 30, 2020
​ | ​ | Gross Carrying | ​ | Accumulated | ​ | Net Carrying
​ |  | Amount |  | Amortization |  | Amount
Patents | ​ | $ | 25,202 | ​ | $ | (8,320) | ​ | $ | 16,882
Distribution agreements | ​ |  | 3,250 | ​ |  | (2,269) | ​ |  | 981
License agreements | ​ |  | 14,425 | ​ |  | (6,244) | ​ |  | 8,181
Trademarks | ​ |  | 30,257 | ​ |  | (11,675) | ​ |  | 18,582
Customer lists | ​ |  | 34,743 | ​ |  | (28,405) | ​ |  | 6,338
Total | ​ | $ | 107,877 | ​ | $ | (56,913) | ​ | $ | 50,964
​
​ | ​ | ​ | ​ | ​ | ​ | ​ | ​ | ​ | ​
​ | ​ | 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
​ Aggregate amortization expense for the three and nine-month periods ended September 30, 2020 was approximately $14.4 million and $44.2 million, respectively. Aggregate amortization expense for the three and nine-month periods ended September 30, 2019 was approximately $15.5 million and $45.2 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 is largely independent of the cash flows of other assets and liabilities. 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 recorded total impairment charges associated with intangible assets in our cardiovascular segment for the three and nine-month periods ended September 30, 2020 of approximately $18.1 million and $20.5 million, respectively. These expenses are reflected within impairment charges in our consolidated statements of income (loss). The primary factors driving impairment of certain intangible assets for the three and nine-month periods ended September 30, 2020 were slower-than-anticipated sales growth in the acquired products, planned closure and restructuring activities, uncertainty about future product development and commercialization associated with the acquired technologies, and economic uncertainties associated with the COVID-19 pandemic. The intangible impairment charges relate to a write-off or reduction in value of intangible assets from our August 2017 acquisition of certain assets from Laurane Medical S.A.S, our license agreements with ArraVasc Limited, intangible assets from our May 2018 acquisition of certain assets from DirectACCESS Medical, LLC, in-process technology intangible assets of Sontina Medical LLC we acquired in connection our February 2018 acquisition of certain divested assets from Becton, Dickinson and Company, and a customer list intangible asset from our October 2017 acquisition of ITL Healthcare Pty Ltd (“ITL”). ​ We recorded intangible asset impairment charges in our cardiovascular segment for the three and nine-month periods ended September 30, 2019 of approximately $2.7 million and $3.3 million, respectively. These expenses are reflected within impairment charges in our consolidated statements of income (loss). The primary indicators of impairment for the three and nine-month periods ended September 30, 2020 were slower than anticipated sales growth in the acquired products and uncertainty about future product development and commercialization associated with the acquired technologies. The intangible impairment charges related to our amortizing intangible assets from our July 2015 acquisition of certain assets from Distal Access, LLC, our June 2016 acquisition of certain assets from Lazarus Medical Technologies, LLC, and our July 2017 acquisition of certain assets from Pleuratech ApS. ​ Estimated amortization expense for the developed technology and other intangible assets for the next five years consists of the following as of September 30, 2020 (in thousands): ​
​ | ​ | ​ | ​
Year Ending December 31, |  | Estimated Amortization Expense
Remaining 2020 | ​ | $ | 14,317
2021 | ​ |  | 49,611
2022 | ​ |  | 48,463
2023 | ​ | ​ | 47,306
2024 | ​ |  | 44,514
​

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