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Goodwill and Intangible Assets
 3 Months Ended
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